Getting your insurance company to cover your weight loss surgery can be easy, or it can be difficult. Much depends on the wording of your particular policy. It might help to think of your insurance policy as a product, that your employer has purchased. That product can be bare-bones, or it can have all the "bells and whistles". Policies can also have specific inclusions or exclusions, which are sometimes asked for by the employer. So the first question is, does your policy "cover" or "have benefits for" bariatric surgery?
If your policy does cover bariatric surgery, then it probably stipulates that it will cover certain types of weight loss operations, but not others. Some cover all of the operations, others only one or two of them. There may be certain BMI criteria, or medical condition criteria that must be met before a certain type of operation will be considered for coverage.
That brings us to the next question, which depends on you, and whether or not you meet the criteria that are set forth in your policy. These criteria include things like BMI, certain medical conditions, how long you've been in the morbidly obese category, etc. Some policies have criteria that are more strict than others. This is where the term "medical necessity" comes in. Each policy tries to define what the standard of "medical necessity" is that a person would have to meet in order for that policy to cover bariatric surgery. It doesn't mean that the operation is an absolute necessity for that person, (though of course it would make a big difference in that persons health and well-being to have that operation!), but it really only pertains to the criteria for that policy to decide that coverage is allowed.
We have people in our office who work with the various insurance companies on a daily basis to help obtain coverage for people to have the operations they need. But there are still many things that you can do to help. In this area, it is very true that the "squeaky wheel" does in fact often get the grease! Below we'll provide some tips that might help you to help yourself in obtaining insurance coverage for your weight loss surgery.
Getting Insurance CoverageHere are some tips that might help you when dealing with your insurance company and considering your insurance coverage:
- Check out your insurance policy. Find out if your policy covers bariatric surgery for morbid obesity, with medical necessity. Some insurance companies have Web sites where you can find this information.
- Call your insurance company. You can help by calling your insurance company. Write down the name and phone number of the person you speak with at your insurance company so that our staff can follow up on the information they give you. Ask the insurance representative for a “call reference number”.
- Copy your insurance card. This will assist us with a preliminary insurance verification check and verification of any co-pays and deductibles that are in your policy.
- Find out if you need a physician referral. If your insurance requires, you will need to get a referral from your primary care physician. Please remember that having a referral from your doctor to our program does not guarantee approval of your surgery. If specific dates are required, please call our office.
- Talk to your family doctor about bariatric surgery. If you do not need a referral, you still need to inform your family doctor that you are seeking this procedure. We may need to contact him or her during the approval process.
- WellStar Comprehensive Bariatric Services does not guarantee that your insurance company will approve you for surgery. We will aggressively pursue getting approval once you become a patient of ours, but ultimately the decision lies with your insurance company.
- If your insurance policy has exclusions or denies you, meaning it will not cover this type of procedure, you have a right to appeal this.
- Not all insurance companies will make exceptions to their policies, but it is worth trying if you can prove medical necessity.
If you want to appeal, the following steps may be useful:
- Ask your primary care doctor to write a letter to the insurance company as to why he or she considers this surgery as medically necessary.
- Ask any other doctors you see to write a letter.
- Insurance companies must tell you what their appeal process is. Appeals are limited and must be handled by you, the patient. Our staff is available to answer questions and guide you through the process.
Insurance Plans We Participate WithWe are making every effort to participate with as many insurance carriers as we can, but there are some barriers that we are working to overcome. We are contracted with, but not limited to, the insurance providers listed in the chart below. While we accept most plans, there may be some we don't participate with at this time. If you are unsure, please call!
|Insurance Company||Policy Product|
||HMO, Non-HMO, Medicare Advantage|
|BC/BS (Blue Cross/Blue Shield)
||PPO, HMO/POS, Indemnity-par and Medicare Advantage|
||PPO and HMO/POS/FLEX/Open Access Plus|
|Coventry, First Health PPO; SouthCare PPO
||HMO and PPO/POS|
|Health One Alliance
|Health Star/PPO NEXT
||PPO, HMO/POS/OA, Medicare Advantage, and WS EE Plan|
|LifeWell Health Partners
|SuperMed (formerly 1st Medical Network)
||PPO and EPO/POS/Open Access|
|Special Net/NOVA Net
|TriCare (Humana Military)
|WellCare of Georgia, Inc.
||Medicaid CMO and Medicare Advantage|
||Only if Secondary Coverage|
WellStar Kennestone Hospital is consistently ranked in the "Top 100 Hospitals" in the U.S.
Our program has treated patients from all over the United States, and from other nations as well.
Please call or email our office for more information about bariatric surgery.
WellStar Comprehensive Bariatric Services
A Certified Bariatric Surgery Center of Excellence
Marietta, Georgia, USA