Planning helps get bariatric insurance approvals!

Sometimes knowing what lies ahead on the road you’re traveling helps you to avoid trouble.

Maybe you know there’s that killer speed bump around the blind corner because you’ve driven that way hundreds of times. Maybe you know to slow down at a certain point because those kids always play just down the cul-de-sac.  If you know what trouble possibly lies ahead on your road it’s much easier to avoid.

The same thing can be said about bariatric surgery insurance requests.  But with one important difference:  While avoiding denials is a nice goal, it must always be balanced with knowing that your bariatric surgery insurance coverage may disappear or get severely limited… so be careful when it comes to spending too much time navigating around the requirements your insurance company puts in your way. AND ALWAYS REMEMBER that just because you don’t meet the insurer’s criteria for surgery doesn’t mean it isn’t medically necessary NOR does it mean that you cannot get approved!  So don’t let your desire to avoid a denial unknowingly cause you to miss the chance to have surgery altogether!   Payer criteria sometimes can’t or shouldn’t be met!   Unfortunately, it isn’t always possible to avoid hearing your insurance payer say “NO”. Quite often their requirements for surgery are unreasonable, impossible to comply with, and simply designed to create so many hoops that patients (and providers) get frustrated and go away, never to be heard from again.

There are some things you can do prior to submitting to your insurance which will either help you get approved the first time or make our ability to appeal quickly and completely that much better.

BE INVOLVED WITH THE WHOLE PROCESS

It’s your health at stake so don’t just sit back and let someone else do it and think everything will be fine. Maybe it will but successfully navigating the insurance pre-approval process requires your involvement as well as the provider’s office. You must be willing to assist with the process. If you’re not sure what you can or should do, get some direction from the insurance specialists at the surgeon’s office. You want to be sure your efforts are not duplicative of things being done, or even counterproductive to obtaining preauthorization.

CHECK WHAT YOUR COVERAGE BOOKLET SAYS ABOUT BARIATRIC SURGERY

If you don’t have your current insurance booklet, get it! You may have to contact the employer or entity providing the insurance or you may be able to access it as a pdf file online through an insurer’s portal like www.myaetna.com or www.myuhc.com.

Once you have the insurance booklet, read it carefully (try to stay awake!), especially the exclusions and limitations sections. If you have it in pdf format you can often use the “Find” or “Search” functions of your pdf reader to locate words like “obesity” or “bariatric” or “weight” – those are terms that will often lead you to important coverage limitations or exclusions

EXAMINE YOUR INSURANCE COMPANY’S MEDICAL CRITERIA

There used to be a time when insurance companies kept access to their coverage policies a more closely guarded secret than nuclear launch codes. It’s slightly easier to find them online and this is where you’ll find out about their dietary requirements, procedures they will or won’t cover, etc.

GATHER MEDICAL AND WEIGHT LOSS HISTORY CHART NOTES AND MEDICAL RECORDS

Usually the most important non-surgeon health care providers from the perspective of assisting with the insurance approval process are in the areas of primary care and and specialist dealing with your obesity-related co-morbid conditions. Don’t just assume the surgeon is getting the records – YOU should take responsibility and once you have them make a copy for your personal use. This will minimize any delays in the event that the payer claims to have “lost” the pre-authorization packet sent in by the bariatric program.

In addition to obtaining medical records you should obtain any available documentation showing your prior efforts at losing weight. This documentation is often essential and if it is provided you can often get a faster approval. Of course, whether such documentation exists and the quality of that documentation will vary greatly, but especially important are chart notes showing medically supervised weight loss efforts. Secondarily, any documentation that shows any professionally supervised (as opposed to “medically supervised”) weight loss efforts. Examples of the latter include Jenny Craig sign-in sheets or contracts, Weight Watcher’s stamp booklets, online logins, etc.

While there is no guarantee that your efforts in these areas will lift the fog your insurer tries to blind you within the hopes that you’ll get frustrated and go away, rest assured these activities will be enormously useful if you have to appeal – – – and most certainly they are your best way of trying to get approved the first time!

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

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