Steps to getting your insurance
company to cover surgery
The best chance for obtaining approval for insurance coverage of your weight loss surgery is by working together with our staff and other allies to prepare a complete, detailed and documented Letter and Application the first time. The experience of other successful weight loss surgery patients proves that teamwork, persistence and attention to detail pay off in the end.
Our message is simple: Getting insurance coverage for your surgery is a battle that in many cases you can win. Don't panic, don't retreat, but realize this may be the battle of your life. Don't rush into it without the proper allies, strategies and tools for success. We will lead you through the time-tested steps to success.
Basically there are 3 steps to obtaining coverage for surgery if you are a candidate, (BMI over 40 or BMI over 35 with…). It is up to you and us, working together, to convince the insurer to cover the costs of the procedure. We must submit an Application to your insurer, which includes a "Letter Requesting Pre-Authorization For Surgery." This letter has two essential, and distinct, goals in mind:
- to have your insurer determine the "medical necessity" for the surgery
- to have your insurer give its "approval" for covering the costs
At this point you might be asking “isn’t getting a determination of ‘medical necessity’ the same thing as getting an ‘approval’?" The short answer, unfortunately, is no. Simply put, an insurer may agree that in your case the procedure is medically necessary, but that your policy doesn’t cover it.
Since you and your surgeon know that you have two goals, you have successfully avoided the first minefield in getting insurance coverage. If you and your surgeon had assumed that a finding of "medical necessity" was enough, you might have been in the position of patients who discovered after surgery that without a specific "approval" from their insurer, they were stuck with all their hospital and doctor bills.
Now you need to convince your insurer the surgery is medically necessary.
more on Insurance Coverage
*TRICARE patients require a referral of the army doctor and a CHAMPUS CLAIM FORM.
Copyright 2005
Professor Rudolf Weiner, MD
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