Does Insurance Cover Bariatric Surgery?
If you are considering bariatric surgery and have questions about how your insurance may cover it, you should contact your insurance provider before making any decisions about whether or not to go through with the procedure. The great news is that, yes, many insurance companies such as Blue Cross Blue Shield, United Health Care, Aetna, Cigna as well as Medicaid and Medicare cover bariatric surgery. Others may provide discounts or be able to submit a letter of medical necessity. If you are a federal employee and selected Blue Cross Blue Shield Federal, you are always covered for weight loss surgery.
One of the most important points to understand about bariatric surgery and insurance coverage is that each insurance company has a set of criteria a person needs to complete before the surgery is approved. In the ideal world insurance companies will follow the same parameters but this is unfortunately not the case. For this reason, it is important that you contact your insurance provider or the bariatric clinic of your choice as they will verify your bariatric benefits. Make sure you have the information early in the process as many bariatric clinics have the tendency of informing the patient at the end of their 3-6 month program. Unfair but real, reason is important that you are informed of your coverage and out of pocket estimate.
What is the cost of bariatric surgery?
How much does bariatric surgery cost?
The average cost for bariatric surgery can range from $12,000 - $25,000 and can be prohibitive for many people. In addition to the surgery itself, you will need to be prepared for the copays and out of pocket expenses 3 - 6 months before surgery. The reason is because you will most likely be required to consult various healthcare professionals for several months such as a psychologist, dietitian, and your primary care physician for medical clearance. You may also need to have a home sleep test, an endoscope, laboratory tests, and EKG before surgery. If you tested positive for sleep apnea, you will need to be set up with a CPAP and proof that you are compliant with the CPAP therapy before the surgery. If the EKG was abnormal, your bariatric surgeon will refer you to a cardiologist for clearance.
What are the Different Types of Insurance Coverage for Weight Loss Surgery?
Weight loss surgery is a type of bariatric surgery that helps people lose weight by restricting the amount of food they can eat. There are different types of weight loss surgery, and each type has different coverage options.
There are three types of weight loss surgeries: restrictive, malabsorptive, and combination restrictive-malabsorptive. Restrictive surgeries reduce the size of the stomach so that less food can be eaten. Malabsorptive surgeries restrict how much food is absorbed in the intestines so that less calories are absorbed. Combination restrictive-malabsorptive surgeries do both restrictive and malabsorptive procedures to make sure they get as much weight loss as possible.
Each type has different coverage options depending on what insurance provider you have or if you have a high deductible plan or not. When calling to verify if your insurance plan has bariatric coverage,
- Deductible
- Copay
- Coinsurance
- Out of pocket maximum
7 Ways to Get Insurance to Cover Bariatric Surgery
With the rising number of people who are battling obesity, bariatric surgery has become a popular option for weight loss. However, many people find it hard to get their insurance company to cover this type of surgery.
The first thing to do is to find out if your insurance provider has a weight loss surgery procedure in their coverage. If they don’t, you can contact your state's insurance commissioner and request that they add weight loss surgery to the list of covered procedures. While in the process, follow these 7 steps to convince your insurance company to cover your bariatric surgery and approve an exclusion for you.
1) Make sure that you’ve tried every other weight loss option available.
2) Find out if your insurance company offers a wellness program that can help you lose weight before you go through with the surgery.
3) Show them evidence that the surgery will be more cost-effective than other options in the long term after you have attempted a non-surgical weight loss program.
4) Find out what they consider "medical necessity" and make sure they understand how important this is for your health and life expectancy. Match your medical records and outline your medical diagnoses with what they consider a medical necessity.
5) Find out what types of care they will provide and what type of care they are not offering.
7) Draft a professional letter asking to have coverage for bariatric surgery and submit.
If still denied, ask if you can speak with a supervisor and always remember to ask for a reference number for the call every attempt you make to communicate with your insurance carrier. In the case your employer has bariatric exclusion, follow the same steps and present your case to the human resources department manager.
Why is bariatric surgery an exclusion?
The insurance provider may offer bariatric coverage, however, the employer decided to remove it from their policy coverage. For example, if you work at XYZ Company who contracted with Aetna, Aetna as the insurance provider may offer bariatric surgery, however, the employer decided to “exclude” from the policy as a way to negotiate a more competitive insurance price plan for that year. In this case, even if bariatric surgery is medically necessary and/or you have the medical qualifications, it is highly unlikely that your insurance provider will pay. You may go to the Human Resources Department and advocate and they may review your individual case.
Another factor to consider is that many times the health insurance decides which type of surgery they cover. This means that you may prefer to have a sleeve procedure but your insurance provider will only pay for gastric bypass procedure.
Another common example is that the insurance has a “one-time lifetime” coverage for gastric bypass. This means they will pay only for gastric bypass and they will not cover any revision surgery in the future. You may prefer a sleeve procedure but your insurance will only pay for gastric bypass.
Different scenario is a situation where the insurance company may have a bariatric exclusion, however, the cost of the surgery if it is deemed medically necessary and may go to what they call a peer review. In this case, the individual will need to take the extra step and communicate with the insurance company, receive a letter of medical necessity from their primary physician, and complete all criteria required by the insurance company before submitting the case for approval. The individual may still be at risk of not being covered as it is the decision of the insurance reviewer team and will be responsible for all applicable co-pays during the process.
What are the qualifications for bariatric surgery?
If you have a BMI of 40 or more and are at risk for health problems, you may qualify for bariatric surgery. If you have a BMI 35-40, some insurance companies may qualify you if you have 1-2 comorbidities such as being diagnosed with high blood pressure, diabetes, obstructive sleep apnea, and/or cardiovascular disease. Insurance will not cover bariatric surgery for an individual with a BMI of 35 without comorbidities. This does not mean you are not qualified for weight loss surgery per se, it only means the insurance won’t pay. Many surgeons globally believe that an individual with a BMI of 35 will greatly benefit from weight loss surgery and be able to have very successful outcomes and enjoy a healthy and fulfilled life long term. Many bariatric clinics have a financial program that will help you budget and manage the cost comfortably. Care Credit is another financial option to pay for weight loss surgery. The application is easy and straightforward.
Bariatric surgery is a life-changing procedure that can help you achieve your weight loss goals. If you are considering bariatric surgery, be sure to check with your insurance provider to see what is covered under your policy. You can also contact a bariatric surgery center to learn more about the procedure and to find out if you are a candidate. With careful planning, you can ensure that you have the coverage you need to pay for your procedure and get the care you deserve.