You may have health insurance but the first item of business is to determine if you policy covers weight loss surgery. Once this is determined, we drill down further and determine the criteria that is necessary to prove medical necessity as this differs greatly from plan to plan. Our bariatric coordinator will assist you in understanding your benefits and the criteria based upon your policy.
Medicare and Medicare Replacements
Medicare and Medicare replacements also cover bariatric surgery. Potential patients must have a minimum body mass index (BMI) of 35 or greater with at least 2 complicating co-morbid condition. Medicare will require a history of obesity (5 years if obtainable), office notes where a physician has counseled you on the need for weight loss, a letter of medical necessity from your primary care doctor, and psychological and nutritional evaluations (coordinated through the office). Medicare also requires patients to be smoke fee for a minimum of 6 weeks prior to the surgery.
Some Insurance companies will require a patient to show documentation of a supervised weight loss program prior to approving bariatric surgery. This type of documentation is obtained by regular follow up visits with a doctor or nutritionist and being counseled on weight loss. Insurance companies do not recognize "fad diet plans" such as Weight Watchers, Overeaters Anonymous, Nutri-systems, or gym memberships. The length of these attempts can vary from 3-6 months depending on the individual insurance criteria. Other items your insurance company may require is a history of obesity, a letter of medical necessity from your primary doctor, and blood work showing you do not have an untreated endocrine disorder. All patients will have a consultation with the bariatric surgeon, be cleared for surgery by the staff psychologist, and attend a pre-operative nutrition class taught by our on-staff dietitian.
Once all documentation is submitted to your insurance carrier, the authorization process can take anywhere from 15-45 days for a response. If your surgery is denied, the insurance company will supply a letter detailing its reasoning and a step by step process on how to appeal.
In the event you do not have insurance that covers bariatric surgery, Sun Coast Bariatrics offers several packages for those who wish to pay out of pocket for weight loss surgery. These packages typically include surgeon, facility, and anesthesia charges. Aftercare at Sun Coast Bariatrics may also be included in the package price. Our Bariatric Coordinator will review the package details with you.
Many patients have been known to take out personal loans or 401K loans to finance their surgery, depending on interest charges. Keep in mind, your surgery may be a tax deduction.
Understanding your insurance benefits
First, we need to determine if you have insurance that covers bariatric surgery. Your insurance carrier will either state "YES, you have coverage for the surgical treatment of morbid obesity". Or, they will say there is an "Exclusion". An exclusion means you do not have coverage for bariatric surgery. It has been excluded from your policy and therefore no benefits are available, regardless of medical necessity. You cannot appeal an "exclusion".
Once you confirm you have bariatric coverage, the next question is "How much do I have to pay"? This is determined by your benefits.
The deductible is the responsibility of the patient. The insurance carrier is not obligated to provide coverage until the deductible has been met.
Co-insurance means your insurance carrier agrees to pay a percentage of your medical expenses but the remaining balance is patient responsibility.
Co-pays are paid by the patient and the remaining balance is paid by the insurance carrier.
Out of pocket
Out of Pocket is the maximum amount a patient has to pay per year. Once the Out of Pocket is met, the insurance carrier will then pay 100% for medical expenses.
The lifetime maximum is the maximum dollar amount that your insurance carrier will pay for medical expenses.
When you have surgery, there are at least three separate entities which will submit claims to your insurance carrier. The claims submitted will be paid according to your benefits, so you should expect patient financial responsibility for:
- The Surgeon
- The Facility
- The Anesthesiologist in most cases the anesthesiologist is out of network
- In some cases, there could be additional charges for laboratory, x-ray and or pathology
Please call us at (727) 289-7137 to learn more about whether you have insurance that covers bariatric surgery. Sun Coast Bariatrics can help you today!