Weight Management

Plan Ahead for Bariatric Surgery: Clearing the Financial Hurdle

January 11, 2019

Plan Ahead for Bariatric Surgery: Clearing the Financial Hurdle

Deciding on bariatric surgery can be the first step in a life-changing journey. Far from a quick fix, the process leading up to surgery alone can take up to six months or longer, depending on how long it takes to address medical, behavioral, and financial factors.

In fact, the first hurdle is often financial. Because the cost of bariatric surgery can range from $16,000 to $24,000, it’s important to know exactly where you stand. For example, planning ahead for long-term costs of vitamins and supplements is important and needs to be factored in when considering bariatric surgery.

Does Insurance Cover Weight Loss Surgery?

Many private insurances cover bariatric or weight loss surgery as a policy benefit. Medicaid and Medicare may also cover bariatric surgery. Keep in mind there are different levels of Medicaid which may vary with your own policy. It is highly recommended, whether you have commercial, state (Medicaid) or federal (Medicare) insurance, to check with your carrier to see if you have the bariatric benefits.

To determine if you are covered, ask your insurance carrier or representative these questions:

  1. Does my insurance plan cover Bariatric surgery?  If this is a second surgery, does insurance cover a second surgery? Have these procedure codes known as CPT codes handy to help the insurance company identify if you are covered:
    • Lap band #43770
    • Sleeve gastrectomy #43775
    • RNY or Gastric Bypass #43644
    • Duodenal Switch #43845
  2. Is “CHI Health Immanuel” in Network?
  3. Is (the doctor you chose) in Network?
  4. What are my requirements to get approved for surgery? (These may include a six-month medical weight management program, bariatric psychological evaluation or other medical requirements.)

The most common reason for denial is an “exclusion to bariatric surgery.” This means your insurance carrier does not have this specific benefit for bariatric surgery. If this is the case, you may not be covered for bariatric surgery, regardless of any comorbidities you may have.

The number two reason for denial is you may not qualify for bariatric surgery for a specific reason. The insurer may deem the surgery not medically necessary or determine that a patient’s body mass index is not high enough to justify surgery. Furthermore, patients may also may be denied as additional clearances may also be required by their insurance carrier during the approval process.   

When a denial occurs, patients may have the opportunity to appeal their denial. Each case and denial are individually based and set by the guidelines of the insurance carrier. Examples of an appeal process are “peer to peer” or by a “written appeal.”  Depending on your insurance carrier’s guidelines, if your case is denied, your insurance carrier will instruct you and/or your surgeon’s office which step you will need to take in order to appeal the denial claim.

Please keep in mind, our team does everything we can to advocate for patients and will work with you to address eligibility requirements and help you through the appeal process if necessary.

Even when insurance covers bariatric surgery, patients are responsible to know their out-of-pocket expenses as well as their deductible. Many insurance carriers state:  an authorization of bariatric surgery does not constitute an assurance of benefit availability or a guarantee of payment. Payment is contingent upon the patient’s eligibility and the availability of coverage for the services provided.

Whether you are covering a deductible or financing surgery on your own, there are several options for covering the costs involved with surgery:

  • Health care or medical credit card
  • Regular credit card
  • Bank loan
  • Home equity loan/line of credit
  • Unsecured medical loan
  • Physician payment plan
  • 401(k) loan

A newer option to explore is MDsave. This online healthcare marketplace allows consumers to comparison shop for specific procedures. MDsave’s upfront bundled price offers savings of up to 60%, and there’s no copay, no billing, and no filing.

While cost can be a considerable hurdle for some, those who deal with limitations due to their weight can find bariatric surgery to be life changing. The benefits of being able to regain mobility and even the ability to work can make any financial investment worthwhile.

If you think you may be a candidate for bariatric surgery, find out where you stand using our comprehensive Weight Management Risk Assessment. Get personalized feedback about your weight risks, learn about possibilities to take control of your weight, and get help from the most experienced experts in the region.

If you’re at high risk, you’ll have the option to request an appointment with one of our weight management specialists.

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