For many people, gastric bypass surgery is affordable because it is a specific benefit included in their health insurance coverage. For those who don’t have this benefit in their plan it is done on a self-pay basis.
Whether your insurance company will cover the cost of gastric bypass surgery or you are paying for it yourself, you will need to prepare detailed written documentation to support the medical necessity of your surgery. Thorough documentation of previous unsuccessful dieting attempts, including medically supervised attempts, co-morbid conditions, and other factors, such as the medications you’re currently taking, can help document that gastric bypass surgery is necessary for the treatment of your morbid obesity. We can guide you through this process.
Advocating Gastric Bypass Surgery Insurance Coverage at Your Workplace
Health insurance is one of the most common benefits offered by employers to their employees. A few health insurance companies have made it a policy not to offer bariatric surgery coverage. However, it is often the case that larger employers decide what health services and procedures are covered under their benefit plan, not the insurance company that administers the health benefits.
If you find that your employer does not offer gastric bypass surgery as part of its benefits package, there are steps you can take. Find out why it’s not covered. It might be beneficial for you to provide your benefits administrator or human resources representative with information about the many benefits of gastric bypass surgery. Often, a quick meeting with the person will tell you how much your administrator knows about the advantages of gastric bypass surgery, such as increased energy levels and a decrease in health problems.
You may find that a combination of your own story, your medical history, and peer-reviewed articles from reputable medical journals will help your benefits administrator understand that morbid obesity is a chronic disease and that gastric bypass surgery is a medically accepted treatment of the disease. By finding statistics that detail the costs of obesity, including the costs of treating obesity, its co-morbidities, and lost productivity, you can present a powerful financial argument stated in dollars and cents. Using this information, the benefits administrator can justify the need for bariatric surgery coverage with the company’s decision maker.
Getting coverage approved by an employer can be a time-intensive process that may require several meetings. Educating coworkers about the surgery and its importance helps to fight society’s obesity bias, and you may find that other people are interested in gastric bypass surgery, too.
Appealing a Denial
If the insurance company turns down your request for gastric bypass surgery, you may be able to appeal the decision. Many people do not take advantage of the appeals process or know of the laws that govern insurance companies in their state. Your health is worth the time and energy it takes to advocate coverage.
It’s critical that you understand your health insurance policy thoroughly, including the number of appeals you are allowed and what, exactly, constitutes an appeal. The number of denials varies among policies and is detailed in your Certificate of Coverage.
Working with Your Bariatric Program Team (Us)
Assistance is key. It is critical that you work with your bariatric program to determine the correct approach to appealing a denial. Your program is there to assist you in this very important process and to help you adhere to your policy’s requirements.
Even when patients have exhausted their appeals processes, they may still have options. Options can include an independent review board, arbitration, and litigation.
Here is some more information about how these three options work:
Independent Review Board
This option is available to people in more than 40 states. Look on your state’s website for filing instructions. No lawyer is required. Judgments usually are issued in 60 days.
Some health plans require patients to use a third party—other than the patient’s lawyer and the insurance company—instead of going to court.
This option is expensive and takes a lot of time. Bariatric surgery is expensive, but patients’ decisions are based on their own resources and desire.
Alternative Financing Options
Few people are able to pay cash up front for gastric bypass surgery. If you do not have health insurance coverage for gastric bypass surgery, but would like to have it, there are alternative financing options available to you.
A popular option is financing with a medical loan. Many bariatric surgery programs work with financing companies to offer a variety of loans to their patients. Your program coordinator and the staff of the bariatric program can tell you more about the specifics.
Important Information for Self-Pay Patients
Self-pay patients, should consider the expense of complications. It’s a good idea to hope for the best and plan for the worst. If you do have health insurance (even if it does not cover gastric bypass surgery), be sure to read your policy. You may find that your insurance company will cover medical costs from complications due to the surgery.
If you are considering gastric bypass surgery and need to find an alternative source of financing, the options are out there.
Talk to Your Bariatric Program Coordinator
If you are interested in alternative financing options, please ask to speak with your bariatric program coordinator. Your bariatric program coordinator should have experience in working with health insurance companies and helping patients find financing for their gastric bypass surgery.