How to get your health insurer to pay for your weight- loss surgery. There's no doubt that Americans are getting heavier: According to a 2. Trust for America's Health, adult obesity rates have doubled in the past 3. Worst off is Arkansas, where 3.
Weight loss goals come in many sizes. New Jersey Bariatric Center® offers the tools and support to find your healthiest and happiest weight.
Some overweight people have turned to bariatric surgery when diets and exercise failed them in dropping weight – excess weight that could cause them major health problems. Bariatric surgery encompasses operations on the stomach such as gastric bypass (open and laparoscopic), laparoscopic adjustable gastric banding, and biliopancreatic diversion. These procedures dramatically restrict one’s ability to eat, thereby causing weight loss. Those who undergo these procedures wind up with a smaller stomach that's able to hold only a few ounces. Eating too much can make that person feel ill.
In addition, some weight- loss surgeries alter the digestion process, limiting absorption of calories and nutrients. The benefits of surgery. According to the American Society for Metabolic & Bariatric Surgery (ASMBS), the mortality rate for bariatric surgery is about 0. And after surgery, patients fare far better than they would have without it. There are a number of obesity- related issues that are often greatly improved as a direct result of the surgery: high blood pressure, sleep apnea, asthma and other obesity- related breathing disorders, arthritis, cholesterol abnormalities, gastroesophageal reflux disease, fatty liver disease, venous stasis and urinary stress incontinence are among the most common. Your doctor may recommend surgery to help you lose weight if you have a body mass index (BMI) of more than 4.
BMI of 3. 5 or more coupled with an obesity- related disease like Type 2 diabetes, heart disease or sleep apnea. A BMI of 2. 5 to 3. A person who is morbidly obese typically has a BMI above 3. Will insurance pay for bariatric surgery? The cost of obesity. Each year, obesity costs the nation more than $1.
This includes $3. Americans age 1. 7 to 6.
Comprehensive list of insurance companies and their requirements to approve coverage for lap bands, gastric bypass, gastric sleeve and other weight loss. How to get your health insurer to pay for your weight-loss surgery. By Insure.com - Last updated: July 11, 2016. Obamacare Weight Loss Surgery Coverage by State (Affordable Care Act) Obamacare weight loss surgery guidelines require insurance companies to provide coverage for all.
Thank you for inquiring about this surgery : In many cases your insurance will cover all/most of the cost of this surgery. If you want to pay cash, the cost can be as. Liposuction surgery can help you if you have trouble reducing fat in certain areas despite diet, exercise or even successful weight loss. The concept of a liposuction.
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People who are obese spend $3. Obese individuals see an increase of 3. The increase in costs associated with medical services to treat obesity and obesity- related conditions is higher than with other studied conditions, such as aging from 3. Source: ASMBS, Health Affairs. The average bariatric surgery costs $1.
ASMBS. Even with your doctor’s recommendation and coverage available from your health insurance policy, your health insurer might not pay for the surgery. According to ASMBS, “insurance denial and unattainable prerequisites were the two most common reasons why some patients do not undergo laparoscopic gastric bypass surgery” and about 2.
If you’re considering bariatric surgery and want your health insurance to pay for it, you may have to jump through a few hoops. It's common to find health insurance companies that will not pay for weight- loss surgery, yet these same insurers are paying for years of treating the conditions associated with obesity. Mounting evidence shows that surgery for morbid obesity can be more cost- effective than treating the conditions resulting from obesity. Neil Hutcher, a practicing bariatric surgeon in Richmond, Va., and past president of ASMBS, sees conditions such as diabetes and heart disease as . Your best chance for attaining insurance coverage for weight- loss surgery is through a group health plan.
But standard health plans do not cover bariatric surgery; an employer must specifically select it as an option. Only six states mandate that treatment for morbid obesity be covered by group health plans: Georgia, Illinois, Indiana, Maryland, New Hampshire and Virginia.
These mandates apply only to group plans, and even then not to group plans offered by self- funded companies. That’s where large employers take on their own financial risk of covering employee claims, and you probably won’t know if your employer is self- funded unless you ask. Finding a goodbariatric surgeon The American Society for Metabolic and Bariatric Surgery certifies . To qualify, the hospital or institution must perform at least 1. The center must also report long- term patient outcomes and have an on- site inspection to verify all data.
In addition, the center must have a dedicated multi- disciplinary bariatric team that includes surgeons, nurses, medical consultants, nutritionists, psychologists and exercise physiologists. To locate a bariatric surgery Center of Excellence near you, visit Surgical. Review. org. The Council for Affordable Health Insurance estimates that mandated obesity coverage adds 1 to 3 percent to premium prices. What you’ll need to make a claim. Know your policy terms before you schedule surgery. Is obesity surgery specifically excluded in your policy?
Do you need pre- authorization? Your insurer will likely require a full medical work- up along with the pre- authorization request plus documented physician- supervised weight- loss attempts. However, weight- loss programs themselves are rarely covered by insurance, and Weight Watchers and Jenny Craig don't count. You'll find out exactly what documents you need when you make a pre- authorization request from your insurer; expect it to involve volumes of paperwork. Coverage for weight- loss surgery varies widely, as do insurers’ definitions of “medically necessary.” Here’s a sampling: Aetna. Aetna does not offer any individual health plan that covers bariatric surgery. Most Aetna group HMO and POS plans exclude coverage of surgical operations, procedures or treatment of obesity unless approved by Aetna.
For Aetna plans that do cover bariatric surgery, here is a summary of the criteria for gastric bypass approval: The patient must have been morbidly obese for at least two years, with a BMI of 4. BMI greater than 3. Type 2 diabetes mellitus, clinically significant obstructive sleep apnea or medically refractory hypertension. In addition to that, you’ll have to: Have attempted weight loss in the past without successful long- term weight reduction; and. Have participated in a “physician- supervised nutrition and exercise program” or a “multidisciplinary surgical preparatory regimen,” each with their own criteria. The full list is available on the Aetna Web site under Clinical Policy Bulletin: Obesity Surgery.
CIGNA Health. Care. Bariatric surgery is specifically excluded under the standard CIGNA Health. Care plan, but employers can elect to include or exclude coverage for bariatric surgery in their group health plans. Some health plans may fall under state mandates for bariatric surgery. When CIGNA coverage is available, a patient is required to have: Reached age 1. A BMI of more than 4. BMI of 3. 5- 2. 9.
Active participation within the last two years in a physician- directed weight- management program. An evaluation within the past 1. CIGNA Health. Care also covers medically necessary reversal for bariatric surgery when a patient has complications and, under certain circumstances, covers revision of a previous bariatric procedure when the patient has not lost adequate weight. How denials are dealt out. Even if you're lucky enough to have bariatric surgery coverage in your policy, brace yourself for a possibly long claims process. At best, you'll need mounds of documentation to show the surgery is medically necessary for you.
Or you may run into big roadblocks. Hutcher says he has witnessed a . For example, an insurer may not cover surgery if you have ? Hutcher's theory, honed from decades as a practicing surgeon, is greed- -with a big dose of discrimination that .
If your HMO plan doesn’t cover obesity surgery, change to a PPO plan at open enrollment if the PPO plan covers it. Change to your spouse’s plan if it provides coverage.
Get a job with Microsoft. This is meant only partially tongue- in- cheek. Certain large employers cover weight- loss surgery as a commitment to employee health.
According to ASMBS, these employers also offer coverage for weight- loss surgery: Intel, Toyota, Fed. Ex Freight, and Harrah’s and Caesar’s Palace.
Consider paying out- of- pocket and ask your surgeon’s office about payment plans. If you’re denied. The Professional Appealer. Walter Lindstrom is one of the best- known advocates in the country for folks seeking to overturn denials for weight- loss surgery. His California law practice (at Obesity. Law. com) evaluates potential appeals on a case- by- case basis by examining your insurance contract and medical records and then preparing a comprehensive written appeal that addresses all the possible reasons to approve the surgery. His office can also represent you at grievance and appeal hearings and prepare you for those hearings.
If your plan doesn’t exclude coverage and you’re denied, appeal it. You will probably need to provide further documentation of your need for the surgery as medically necessary. All health insurance plans should have a clear appeals process. Find out what it is and follow directions.
You may only have a limited time from the date you were denied or had the procedure to get an appeal under way, possibly only 6. Depending on your plan's procedure, you might have to start with a phone complaint, and then move to a written appeal. Hutcher advises individuals to call their insurer every day: “Be the squeaky wheel. Some bariatric surgeons even have . There are two methods of appeal: internal and external.
The internal appeal is to the insurer itself. An external appeal is to your state department of insurance or other governing body. If it's time to shop for a new health insurance provider, you can review the best health insurance companies according to surveyed policyholders to help make your decision.
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