Fit-N-Wise Bariatric Solutions

Financial & Insurance Information

Please do not let money stand in the way of improving your health and well being. Weight Loss Surgery may or may not be covered by your insurance company. Some insurers and certain plans will pay for Gastric Bypass and some will pay for the LapBand. The financing on these two different procedures have some common features, but it is very different, so read each section carefully for more information.

The Differences in Insurance Plans.
Insurance companies are very different, and each insurance company has a number of plans. Your written policy may have a number of different phrases that can be interpreted in various ways by the administrators of the plans, such as “obesity” versus “morbid obesity”, “medically necessary”, “experimental” etc. Many insurers recognize the long-term benefits of our program, and their approval process can be routine. Others are just becoming aware and can it can be very difficult and lengthy to get verification of benefits. It is a good idea to read your policy very carefully and to speak with their representatives if necessary. Our insurance experts at Wise Regional Health System and the insurance experts at your surgeons’ office may be able to help you sort through this. We have specific information and criteria for a number of local insurance plans and we might be able to give you some specifics based on our experience with these plans.

Insurance Request: The Letter of Medical Necessity
Once you have provided your surgeon and the program a completely filled out set of preoperative forms (accept our apologies for their great length) and the appropriate supporting documentation, you will have a consultation with the surgeon. It is helpful to obtain benefits for surgery by getting a letter of support from your primary care physician as well as specialists and mental health providers who care for you. Your surgeon will prepare a Letter of Necessity to your insurer, written with their specific criteria for weight loss surgery.

Please take note that it takes a highly variable amount of time for all the information to be gathered and to have the letter of necessity prepared. We may have to wait for certain documentation to send it. This process can take many weeks, so please be patient. After your insurance company receives your letter, they may send a confirmation of benefits to us expediently or they may take a unpredictable amount of time. This also may take weeks or months.

Once you have verification of benefits for weight loss surgery from your insurance carrier, we can then generally schedule a surgery date. Availability of operating room opportunity can vary, and once again you may have to be patient. Overall, it may take many months between your personal decision for weight loss surgery and your actual surgery.

Pre-Operative Consultation and Testing.
There will be costs associated with pre-operative consultation and the pre-operative testing necessary to determine that you are an appropriate candidate for Weight Loss Surgery. Depending on your health and your surgeon’s concerns there may be tests and consultations done to assess the exact state of your health, and in order make your surgery safer. Your insurance company may not cover this. You may want to discuss this up front with your insurance carrier and/or with your surgeon at the start of your consultation.

Dietary Counseling.
You will meet with our program specific registered dietitian and will receive an extensive manual on how to use your “weight loss tool.” Your need to intimately understand the lifestyle changes necessary to be successful after weight loss surgery before you make your final decision for surgery. Your insurance company may not cover this dietary counseling. Our program specific dietitian has significant training and experience specifically in the education of patients prior to weight loss surgery. Our dietitian understands the surgery; it’s postoperative demands and shares the surgeon’s philosophy of evaluation and care.

Psychological Evaluation.
It is necessary for you to undergo a psychological evaluation before your surgery. Some insurance companies require it, however we insist on this to determine that you are not only an appropriate candidate for surgery, but it is the right time in your life to undergo the dramatic life change that weight loss surgery will provide. Weight loss surgery candidates are NOT crazy, and they have been shown to have no more concerns than normal weighted people. We feel this evaluation contributes significantly to the safety of the surgery and postoperative life. Your insurance company may not cover this psychological evaluation. Please discuss coverage with our program specific psychologist. We do value the input of your own psychiatrist, psychologist, or counselor, but our psychologist has significant training and experience specifically in the evaluation of patients for weight loss surgery. Our psychologist understands the surgery; it’s postoperative demands and shares the surgeon’s philosophy of evaluation and care.

Weight Loss Surgery is often covered by insurance policies and the amount that it costs depends upon the type of policy and its terms.

Gastric Bypass. Insurance companies usually cover post-surgery follow-up visits of an uncomplicated surgery for 90 days (it is included in their payment for the surgery).  Patients paying cash for Gastric Bypass must discuss with their surgeon what is covered and for how long.  We have a very formal follow-up program with this operation at 2 weeks, 1 month, 3 months, 6 months, 9 months, 1 year, 18 months, and every year after that around the anniversary of your surgery. We highly recommend lifelong follow-up by your surgeon. We also have a substantial lab testing regimen that you may be financially responsible for. For the most part, some insurance companies pay for this follow up and some will not. Vitamin therapy is absolutely mandatory after Weight Loss Surgery, and you will be responsible for purchasing (and taking) daily vitamins. Insurance carriers generally will NOT cover vitamin therapy and they can be quite expensive. Please educate yourself before your surgery and ask questions to get more complete information. We cannot guarantee that you will not have out of pocket expenses associated with proper follow-up of this life changing surgery.

LapBand. Patients must ask their surgeon what is covered and for how long after surgery.  Different surgeons provide a certain number of office visits and band fills/adjustments after the surgery for a certain period of time.  If your insurance does not cover band fills/adjustments or if you paid cash for your band, you may be responsible for payment for these services.  Ask your surgeon before surgery what is included in the price of surgery.  Ask if the band fills/adjustments are done in the surgeon’s office, a hospital or an outpatient ambulatory surgery center, outpatient imaging center or another facility.  Ask if these facilities have charges attached to their services. 

The Cost of Complications.
Whether you have the LapBand or the Gastric Bypass, you may be financially responsible for complications. We try to minimize the chance of complications and the patient has a major role in helping to avoid complications. Nevertheless, if you have or are even suspected of having a complication it may necessitate some very expensive testing, hospital admission, or even surgery. We cannot guarantee that your insurance company will cover these costs, although some might. The coverage for LapBand may differ from the Gastric Bypass patients.

Cash pay patients and Complications: Please think very carefully about and speak to your insurance company and your surgeon if you are paying cash for your operation regarding your financial responsibility if complications happen after surgery.  If your insurance policy does not cover these complications, you will need to pay for any office visits, surgery, hospital admissions, emergency room visits and any tests or       X-ray studies that are done. 

If You Get a Denial for Benefits for Weight Loss Surgery
Occasionally, insurance companies will deny an initial application for benefits, even when well substantiated, and well within the consensus criteria recommended in the NIH report. Sometimes they cite a technicality of your specific policy. It may be difficult to figure out why there was a denial. Be cautioned that you may have only so many opportunities for appeal, and they should not be wasted. If you get a denial, please speak to the insurance experts at your surgeon’s office. You and your surgeon may decide to change something and resubmit. However, there are certain cases when we can no longer help.

If your insurance carrier remains unreasonable, you may wish to seek legal assistance in obtaining good faith coverage of your medical needs. For information on legal assistance, you can contact your lawyer or you can use your internet search engine to look for obesity law specialists or other legal services. 

If your employer's health insurance does not cover weight loss surgery, you may still have options. For example, your spouse's plan may provide coverage and you may be able to sign up during the next open enrollment period. Or, you may have success making an appeal to your employer to upgrade their plan or to change insurance carriers who do provide benefits for weight loss surgery. More and more employees need to make their wishes known to their employers. More and more employers need to put pressure on insurance companies to provide reasonable ways to get their employees benefits for weight loss surgery. Please be a voice for all the good people that need this surgery.

Advance Payment Option

If you do not have insurance, if you followed your insurance company’s guidelines for approval and are denied, or if you would prefer to bypass the insurance approval process all together, you have financing options available that may make your weight loss goals a reality.  Here are just a few options available:

• Care Credit
• Capital One
• LapBand Financing (www.lapband.com/lapband/costandinsurance.do)

For more information on a specific option, please speak with your surgeon’s office or visit Obesity Help for support information

http://www.obesityhelp.com/morbidobesity/bariatric+surgery+insurers+in+texas.html

Remember that tax law will usually allow weight loss surgery to be tax deductible. Talk to your accountant or tax professional.