“June Gloom” & Bariatric Surgery Insurance Denials

Failing to plan in June may spell disaster in December!

Failing to plan in June may spell disaster in December!

Bariatric Surgeons and Their Patients Need To THINK AHEAD As June Approaches!

Living in San Diego certainly is a blessing and I know that nobody is going  to listen to us complain about our weather.  But believe it or not, it isn’t always perfect. As Memorial Day approaches, with June not too far behind, we always seem to get a 30 day marine layer lovingly called “June Gloom” that casts our whole area in patchy gray with far too little sunshine. Thankfully that disappears right around the 4th of July.

So what does this have to do with weight loss surgery patients and their insurance coverage you ask?  PLENTY!

If you and your doctor have recently determined bariatric surgery is the right choice for you AND you have insurance coverage for surgery under your present plan, congratulations.  But be very, very careful not to lose that coverage!  There are many people whose insurance plans change mid-year, and sadly some of those plans inevitably change from one which covers weight loss surgery to one which does not.  June may indeed lead to Gloom for someone unaware of that possibility.  Are YOU sure you know when your plan might change?  If not, find out and be prepared to move quickly toward that Operating Room.  I hope you are working with a surgical program which is FLEXIBLE and understands the urgency of someone who is about to lose their bariatric benefits.

So does that mean you’re in the clear if your plan doesn’t change until 2014?  Not necessarily……..

Let’s say yours is one of the many insurers who “require” this absurd “six-month supervised weight loss program” as a major hoop to jump through before getting approved.  Let’s also say your surgery program, with the best of intentions to make your insurance approval as easy as possible, starts you on some type of diet program so you can document that 6 months for your insurance.Just one more thing! If I count correctly (using the fingers of both hands, of course), that means your insurance company isn’t going to hear from your surgeon until November or December at the earliest.

Now imagine your employer or other sponsor of your health insurance plan sends out a memo or announcement saying they are changing to a new insurer in 2015.  Maybe they say this is “cheaper but it has the same coverage.”  Maybe it does – but maybe it doesn’t for the treatment you need:  bariatric surgery.  You learn that the new plan EXCLUDES surgery.  What now?  Suddenly you’re in the middle of a supervised diet and facing a loss of coverage. 

REMEMBER that if your insurance is going to change it is the insurance you have on the DAY OF SURGERY which is important, NOT the insurance in place when you started the process of getting approved or when you began your supervised diet!

A failure to PLAN AHEAD in June might cause terrible Gloom in December or January.  That’s why we tell bariatric programs and patients alike:

NEVER DELAY SUBMITTING A PATIENT FOR INSURANCE APPROVAL!

When a patient qualifies for surgery AND has insurance coverage for that surgery, it is important to act quickly even though it is only the middle of the year. It is better to submit a preauthorization to the insurance plan, EVEN AT THE RISK OF THEM DENYING YOUR REQUEST, because going through the appeal and independent review process while the calendar still has a lot of months left is more likely to result in an approval so surgery can happen with your bariatric benefit still in place.  Otherwise you will find yourself near the end of the year WAITING and HOPING they say Yes.

By waiting you are RISKING that you might be one of the unfortunate ones whose failure to plan well in June caused them terrible Gloom at the end of the year, even though they thought – and their bariatric program thought – jumping the silly hoops and playing by the insurance plan’s rules was the right thing to do.  So if your bariatric program is talking about having you wait and jump through more hoops show them this post and get them to re-think that plan.  It could be a terrible but avoidable mistake.

DON’T MAKE THAT MISTAKE.  PLAN AHEAD AND TAKE THE POSSIBILITIES OF “GLOOM” OUT OF YOUR JUNE!

601-C East Palomar Street #480 Chula Vista, California 91911 Tel - 877-992-7732 Fax - 844-384-9199

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