Due to the high cost of gastric bypass surgery, most patients who are considering it will look to their health insurance policy to cover at least a portion of the cost. Some insurance policies will not cover any obesity-related treatments, but those that will almost always require preauthorization for weight loss surgery.
Your doctor and surgeon may have a financial interest in assisting you in obtaining Life Insurance benefits, but the burden of paying for your surgery falls primarily on your shoulders. You should do everything possible to make the process for your doctor’s staff as simple as possible.
The medical policy that applies to weight loss surgery is separate from your benefit policy. It’s a document that lays out the coverage rules for this particular procedure. Most major medical treatments and diagnoses are covered by your insurance company’s medical policy, which often includes the company’s criteria for “medical necessity.”
Patients are frequently perplexed by the clause in many health insurance contracts that defines the term “medically necessary.” People naturally believe that if their doctor says a procedure is necessary, the insurance company will agree. However, their interpretation of “medically necessary” may differ from that of your physician.
This doesn’t mean the procedure isn’t necessary for your health and well-being; it simply means that your health insurance company isn’t required to cover the cost.
That is why, before making any financial decisions about your treatment, you should carefully read the insurance company’s contract and medical policy.
The surgical costs will almost certainly not be covered if your insurance company requires preauthorization and you proceed with treatment without going through the preauthorization process. This could be a costly blunder that could easily be avoided.
When the insurance company receives your pre-authorization request, their medical staff will review the information provided by your doctor and determine whether or not the criteria set forth in their medical policy have been met.
Your doctor’s assessment of your need for gastric bypass surgery must be supported by facts and chart notes. Although a surprising number of doctors send one in anyway, a letter from your doctor that basically says “because I said so” will not impress your insurance company.
If you don’t meet the insurance company’s benefit requirements, you might want to think twice about having the surgery. The surgery is not without risks, and it should only be done if there are compelling reasons to believe it is necessary. If it’s necessary, your doctor should be able to explain why in a way that other medically trained professionals can understand.
If your request for preauthorization is denied, you may be able to appeal the decision if you meet certain criteria:
- Your policy covers bariatric surgery,
- You meet the medical policy’s eligibility requirements,
- Your doctor has submitted all of the required documentation,
The appeals process, if any, will be detailed in your benefit handbook, and you should pay close attention to the amount of time you have to file an appeal and what forms you’ll need to get started.
Every state’s insurance law is different, and every insurance contract is unique. If you have any questions about your policy’s benefits or rights, seek legal advice from someone who is familiar with your state’s insurance laws. You will have the best chance of receiving all of the benefits that your health insurance premiums are paying for if you have a clear understanding of your benefit contract.