Common Insurance Requirements for Surgical Treatment for Morbid Obesity

Insurance Coverage of Bariatric Surgery

Volumes of medical data demonstrate the health benefits and cost effectiveness of bariatric surgery, but health insurers remain generally resistant to providing coverage for bariatric surgery. The reasons for this perplexing situation are complex and not fully understood, but the current situation is that coverage for medically appropriate surgery is spotty. Often, when surgery is available as a covered benefit it is supported only after a patient clears a number of administrative “hurdles” that the insurer uses to reduce accessibility such as requiring a 6 month diet, or 5 year weight history, etc.

We are hopeful that additional data now being gathered will help health insurers decide to improve coverage of medically necessary treatment such as bariatric surgery. In the meantime, we advise patients to be vocal and persistent in seeking insurance funding for the healthcare they need. This usually means taking the issue to the HR department at your workplace. New Dimensions strongly encourages anyone with access to health care insurance funding to pursue that option.

Contacting Your Health Insurance Company

Patients should contact their health insurer directly and as early as possible in the process of surgical preparation. As an individual with health insurance coverage, you are a customer with the right to require information and service from that company. If you are told by your health insurer that bariatric surgery is not covered, don’t be put off or discouraged. We often find that erroneous information is conveyed if questions are not posed in an exact manner. Once someone has attended an Informational Seminar and if he or she is interested in pursuing surgery, our staff will assist patients in their efforts to obtain insurance approval. Patients who actively participate in the insurance pre-authorization process by calling and inquiring with their insurance company are a significant stimulus for insurance companies to respond favorably.

Another helpful way to get information about whether bariatric surgery is a covered benefit, and what are the conditions required for a patient to meet, is to call the REALIZE™ Band support center at 866-REALIZE. This support center can also help get information for patients who are interested in the gastric bypass or gastric sleeve.

Health Insurance Co-Pays

For patients who are covered by insurance, New Dimensions will bill the insurance company directly; however, most patients are responsible for co-payments at the time of initial consultation and for deposits prior to surgery. Anticipated co-pays for the surgical procedure itself must be paid by the patient at the time of the pre-operative preparation appointment, usually about one week prior to surgery.

Blue Cross Insurance Patients

For patients who have coverage with Blue Cross, New Dimensions surgeons are “out-of-network.” New Dimensions can still do your surgery, and we are always working to minimize the impact of this awkward situation for patients. Please talk to our staff about the specifics of your case.

New Dimensions would prefer to be in-network for bariatric surgery for BlueCross patients, but Blue Cross is the only health insurer that has been unwilling to have a substantive discussion with us about the terms of a network agreement. If any patient can help us engage in a substantive discussion with BlueCross we will be very appreciative.

Employer Benefits

Employers who invest in the long term health and functionality of the workforce should see the inclusion of a bariatric surgery benefit as a favorable move for their company. Patients may be able to affect an employer’s benefit plan by working with their employer’s benefits department to include treatment of morbid obesity. To assist in such an effort, any of the New Dimensions surgeons are available to speak directly with any employer who is considering including bariatric surgery as part of their wellness and weight management plan.

Legal Assistance & Community Support

Sometimes a patient really should be covered by insurance, but the health insurer refuses. In these situations it may be appropriate to obtain legal assistance. One useful source of such assistance is the Obesity Law and Advocacy Center. Patients who are struggling with coverage issues should also consider joining the Obesity Action Coalition, which is a national group advocating for the rights and needs of obese people.

Self or Cash Pay

For patients who do not have access to insurance coverage and who wish to utilize the “self or cash pay” option some of the hospitals with which we work each have created a single lump-sum, fixed fee schedule for bariatric surgery. The fixed rate we have arranged means that a patient can know with reasonable certainty what their surgery is going to cost before it happens.

The rates for the several facilities at which we operate change with some regularity