How To: Check If your Insurance Company Covers Bariatric Surgery
Your first call to your insurance carrier is to collect information about your policy. You will want to see if they will cover Lap Band Surgery, Gastric Bypass Surgery and Gastric Sleeve Surgery.
First Step: Before Calling the Insurance Company
- Research and select a couple of bariatric surgeons you are interested in.
- For each surgeon, check our site to see if information is available about what dietician and psychologist that surgeon usually sends his or her patients to.
- Start a folder to contain paperwork for all your insurance dealings and be ready to take notes from your call for safe keeping here.
Calling Your Insurance Company to Check Coverage: What To Ask
- Record Everything! When you start speaking with the service representative at your health plan, record the name and ID number of the person you speak with and the date and time of the conversation.
- Ask your health care insurance representative what policy they have on specific “CPT codes”. Health plans approve medical procedures based on diagnosis codes. The diagnosis code for morbid obesity is 278.01. The medical industry codes procedures with things called CPT Codes. Bariatric surgery has a bunch of these CPT codes, depending upon which procedure type (lap band, duodenal Switch ect.) is used .
- These are a list of CPT codes for Bariatric Surgery. Go through each code with the health policy representative, ask them what their reimbursement policy is. They can say something like 'approved if medically necessary'. Another possibility is that they have what is called a 'written exclusion policy'. Make sure that you carefully record what they say for each code.
43846 Short limb RNY 43847 Long limb RNY 43659 Laparoscopic 43847 Duodenal Switch 47600 Duodenal Switch Related 43633 Duodenal Switch Related 43659 Adjustable Gastric Banding (Lap Band)
- Find out if the list of surgeons you would like to use are “in network” or “out of network”. Provide the representative with the names of surgeons you have researched and they will tell you if each surgeon is in or out of network. The coordinators at the surgeons office can also do this for you.
- It is important to find out about reimbursement amounts and alternatives. You might have a small co-payment with one of the surgeons, while with another surgeon, you still have coverage but with a higher co-payment. Record all this in your notes.
- Ask about coverage for psychologists and dieticians. Most health plans require a letter from a dietician and also a psych evaluation from the psychologist (or psychiatrist).
- Confirm referral requirements. See if you need to be referred to the dietician and psychologist by your primary care physician, or can you make an appointment with them directly. You should also confirm whether you need a referral from your primary care physician in order to see a specific bariatric surgeon.
- Ask the insurance representative about the letter of “Medical Necessity”. Health insurance plans normally will not authorize coverage for bariatric surgery without a letter of “medical necessity”. It is usually written by the bariatric surgeon and explains why surgery is non-cosmetic and a life-saving procedure. Ask your insurer if the letter must come from the bariatric surgeon, or if they would accept one from your primary care physician.
At this point you should have a solid understanding of what your insurance company will and will not pay for.
Your bariatric surgeon’s office will be able to help you move forward with fulfilling all the requirements your health insurance provider requires.
To find more information on the coverage of bariatric surgery for these health insurance providers, follow link.
Aetna, Anthem Blue Cross, Blue Cross Federal, Blue Cross National CareFirst, Blue Cross of Alabama, Blue Cross of Arkansas, Blue Cross of California, Blue Cross Blue Shield of Delaware, Blue Cross Blue Shield of Florida, Blue Cross Blue Shield of Georgia, Blue Cross Blue Shield of Illinois, Blue Cross Blue Shield of Massachusetts, Blue Cross Blue Shield of Michigan, Blue Cross Blue Shield of Minnesota: Blue Cross Blue Shield of Mississippi: Blue Cross Blue Shield of Nebraska: Blue Cross Blue Shield of New Mexico: Blue Cross Blue Shield of North Carolina: Blue Cross Blue Shield of North Dakota: Blue Cross Blue Shield of Oklahoma: Blue Cross Blue Shield of Tennessee: Blue Cross Blue Shield of Texas: Blue Shield of California: Champ VA: Cigna: Empire Blue Cross: Excellus Blue Cross: First Health: Health Scope Benefits: Horizon Blue Cross Blue Shield of New Jersey: Humana: Independence Blue Cross: Pacificare Secure Horizons: Premera Blue Cross: Principal Financial Group: Regence Blue Shield: Unicare: United Health Care: United Health Care THR: Wellmark Blue Cross Blue Shield:
My Insurance won’t cover Bariatric Surgery: What options do I have?
The health plan you have may have a “Written Exclusion Policy”. Don’t fret just yet, you still may have some options.
Consider getting an additional “add-on policy” that will cover your bariatric surgery. An example is Anthem insurance. Most likely, premiums will be very high, but depending upon what plan you are able to get, it might be better in the long run.
Change Health Plans with your Employer
You can wait for open enrollment for the health insurance at your employer or your spouse's employer, at which point you might upgrade from an HMO to a PPO. Or, it might mean changing employers.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that:
- Limits the ability of a new employer plan to exclude coverage for preexisting conditions;
- Provides additional opportunities to enroll in a group health plan if you lose other coverage or experience certain life events;
- Prohibits discrimination against employees and their dependent family members based on any health factors they may have, including prior medical conditions, previous claims experience, and genetic information; and
- Guarantees that certain individuals will have access to, and can renew, individual health insurance policies.
Cash and financing
A final option is to simply expect to self-finance your surgery with cash. Bariatric surgery is a life-transforming change affecting the rest of your life. Unless your health is rapidly deteriorating, you might save yourself a great deal of emotional turmoil by taking the time to save up for surgery. Depending upon how much money can be borrowed from other sources, this could take a year or several. Note, though, that financing is available for the procedure. Hospitals and surgeons around the country often offer special cash rates to people without insurance. Through saving, borrowing, and institutional financing, bariatric surgery is as within reach as a $20,000 automobile might be. Insurance might or might not be of help to you. It shouldn't, however, by any means have any final say in what you do with your life.