A growing number of states have passed legislation that requires insurance companies to provide weight loss surgery benefits for patients who meet certain criteria. While insurance coverage for weight loss surgery is widespread, there is often a lengthy, complicated approval process. Here are some of the key steps you should take to obtain approval from your insurance company for weight loss surgery:
Read and understand your certificate of coverage. Your insurance company is required by law to provide you with this document. If you do not have a certificate of coverage, consult your employer's benefits administrator or ask your insurance company directly.
Start with your primary care physician. In most cases, your primary care physician must refer you to a qualified bariatric surgeon. Even if you are not required to get a referral, it is a good idea to have the support of your primary care physician.
Organize your medical records. Before visiting your bariatric surgeon, it's important to gather information about your health, including your history of dieting efforts. These valuable documents will be used at every stage of the approval process.
Document every visit. When you consult with a health care professional or participate in a supervised weight loss program for obesity-related issues, it's important to track this information. Document weight-loss attempts through joining diet centers and fitness clubs. Keep good records, including receipts.
If your initial request for pre-authorization is not approved, you still have options. Insurers provide an appeals process that allows you to address each reason they have denied your request. It is important that you reply quickly. You may also want to enlist the help of an experienced insurance attorney or insurance advocate to properly navigate the complexities of the appeals process. Some insurers place limits on the number of appeals you may make, so it is important to be well prepared.
With your insurance card in your hand, call the customer/member services phone number listed on the front(usually back) of your insurance card. Tell the representative that you would like to "check your policy benefits". Ask the following:
1. Is Bariatric Weight Loss surgery a covered benefit? Listed below are the procedure codes for the three surgeries that our office performs.
The diagnosis code or ICD 10 code that we would be billing with is: E66.01
2. Does this benefit require a medically supervised weight loss program? If yes, what is the program length?
3. Is a referral from your primary care doctor required for a consultation with the surgeon?
Always keep track of who you speak with, the date and a referance number for your call.