Gastric bypass surgery is expensive, so most patients considering this procedure will look to their health insurance policy to cover at least part of the cost. Some insurance policies will not cover any obesity-related treatments, but those that will pay for weight loss surgery almost always require preauthorization.
This means that your insurance company will probably ask for medical records, a treatment plan, and perhaps a letter from your primary doctor and surgeon to show that you meet their criteria for benefits. Your doctor may be required to show that you have attempted weight loss in the past through other, less dangerous methods, and have failed.
If you have not already read your insurance company’s medical policy on gastric bypass surgery, you should do so before you ask your doctor to request pre-authorization. Your doctor’s staff may already have a copy of the medical policy, but if they don’t, it is always helpful if you provide this to them. If it isn’t available on your insurance company’s website, they should be mail you a copy if you ask for it.
Your doctor and surgeon may have a financial stake in helping you get insurance benefits, but the responsibility for finding the funds for your surgery is primarily on your shoulders. You should do everything you can to make the process easier for your doctor’s staff.
The specific medical policy concerning weight loss surgery is a separate document from your benefit policy – it is a document that lays down the rules for coverage for this specific procedure. Your insurance company has a medical policy for most major medical treatments and diagnoses, and the medical policy often includes the company’s criteria for “medical necessity.”
One thing that often confuses patients is the clause found in many health insurance contracts defining the term “medically necessary.” People naturally assume that if their doctor says a procedure is needed, the insurance company will accept this as true. However, their definition of “medically necessary” may be different from your doctor’s.
This doesn’t necessarily mean that the procedure isn’t needed for your health and well-being – it simply means that your health insurance company doesn’t have to pay for the surgery.
That’s why you want to read the insurance company’s contract and medical policy carefully before making any financial decisions about your treatment.
If your insurance company requires preauthorization and you go ahead with treatment without going through the preauthorization process, the surgical costs will probably not be covered. This could be a very expensive mistake, and it can easily be avoided.
When the insurance carrier receives the pre-authorization request, their medical staff will go over the material provided by your doctor and decide if the criteria listed in their medical policy have been met.
Your doctor’s opinion about your need for gastric bypass surgery will need to be backed up by real facts and chart notes. A letter from your doctor that basically states “because I said so” is not going to impress your insurance company, although a surprising number of doctors send one in, anyway.
If you do not meet the insurance company’s criteria for benefits, you may want to carefully reconsider your decision to have the surgery. The surgery is not without risks, and should not be undertaken without very strong facts showing that it’s needed. If it is needed, your doctor should be able to say why in a way that is acceptable to other medically-trained professionals.
If your request for preauthorization is turned down, you may be able to appeal the decision if:
– Your policy covers bariatric surgery,
– You qualify under the medical policy’s guidelines, and
-Your doctor has provided all the documentation that was requested,
The appeal process, if any, will be carefully outlined in your benefit handbook, and you must pay special attention to the amount of time you’re given to appeal, and what forms you may need to get the process started.
Remember that even if you have a right to appeal, you will need additional evidence not previously provided to the insurance carrier, unless the previous decision was clearly made in error. And there is no guarantee that the previous decision will be overturned.
Insurance law varies in every state, and every insurance contract is different. Be sure to seek legal advice from someone familiar with your state’s insurance laws if you are not sure about your benefits and rights under your policy. A clear understanding of your benefit contract will give you the best chance of receiving all the benefits that your health insurance premiums are paying for.
Source by Jonni Good
