A word about insurance:
You might be surprised to learn that many insurance companies
will cover the treatment of health problems caused by obesity
but not obesity itself or that a conclusion that a particular
service is medically necessary does not constitute a warranty
that treatment is covered (i.e., will be paid for by your
insurance) for a particular member. So it is a good idea to
have a basic understanding of what your insurance will cover
prior to setting up a meeting with a bariatric surgeon.
In general, insurance companies require a Body Mass Index
(BMI) of 40 or higher. A BMI of 35+ may be allowed depending
on the number and severity of the patient's related comorbidities.
Remember, surgery is a last resort treatment meaning you have
tried and failed to change any one or combination of the following
environmental/behavioral (dietary, physical exercise)
Where do I start?
It all starts with your primary care physician. You need this
person on your team to help you begin to build a case of medical
necessity that is documented and signed by your regular physician.
To get preapproved you will need to provide your insurance
with information about the bariatric surgeon you will be seeing.
You should set up an appointment to attend a free seminar
where we will discuss the risks and benefits, procedures and
how your body will be changed, and the necessary lifestyle
changes associated with gastric bypass surgery.
If the doctor initially believes that you could be a candidate,
additional tests may be necessary to support and validate
your need for surgery. Once the practitioner has concluded
that you are a candidate for surgery, he/she will notify your
insurance company requesting authorization for surgery based
on your medical conditions that would most likely improve
with bariatric surgery.
Generally, most institutions will require you to also see
the various specialists for pre-operative clearance. Your
surgeon or primary care physician can refer you.
In the end, all of this preparation could go to waste if
you are not ready to make this life long - life style change.
Like an investment, your surgical weight loss institution
will be investing a lot of time and effort and you will be
investing in your life. So, the assessment of your motivation
is a prerequisite for weight loss therapy. For these reasons,
motivation for weight loss should be high before initiating
your plan of action and usually your doctors will be very
conservative in their evaluations. They will assess your attitude
and reasons to gage your motivation and seriousness, they
will inquire about your outside support team and your environment,
they will insure that you have educated yourself and understand
your obesity and its associated risks, and will attempt to
gain an understanding as to the reasons any previous attempts
at weight loss or maintenance of normal body weight failed
or succeeded and will explain how this treatment plan will
be different. And lastly, the financial considerations such
as having to pay for travel to the medical facility, time
lost from work, and paying for professional counseling that
is not covered by insurance.
Your practitioners office will usually contact your insurance
company often to get a status report. It can take as long
as a month and a half to hear from your insurance company.
Once surgery is approved, your surgeon's office will call
to notify you.
Usually after the insurance authorization is confirmed, you
will usually be seen again by your physician. This time a
physical examination will be performed and your surgery will
be scheduled. You may also be asked to complete a questionnaire
related to bariatric surgery and to sign a disclosure statement
regarding operative risks and blood transfusions. You will
probably be scheduled for a pre-operative seminar. This seminar
is designed to give you an overview of your hospital experience,
and give you specific information about pre-operative and
post-operative hospital procedures.
Financial and Insurance Issues
The average time in the hospital is 2 days for laparoscopic,
and about 3-5 days for open gastric bypass, depending on your
surgery. Recovery time is about 2 to 6 weeks depending on
the type of operation, your condition, the type of work that
you do, and other factors.
The cost of the operation includes:
• Hospital fees
• Surgeon fees
• Anesthesia fees
• Lab and x-ray fees
• Miscellaneous fees
Many insurance companies will cover the full cost of bariatric
surgery. We will need to document for them that your bariatric
surgery is a medically necessary procedure done because of
specific health concerns. We may also need to provide specific
documentation depending on your policy to show that:
• You have tried and failed other non-surgical weight
• You have undergone nutritional counseling
• You do not have major psychiatric or emotional problems
that would make surgery unsafe
We can usually help you to meet many of these requirements.
Some insurance companies have specific language in their policy
that excludes payment for bariatric surgery. Unfortunately
most of the large Health Maintenance Organizations (HMOs)
fall into this category.
If you have such a policy, or your plan does NOT cover "out
of network" physicians, or does not approve you for surgery,
or if you are uninsured, you may want to consider financing
the surgery. Many patients choose to pay
for the operation themselves. We can arrange for you to
meet with a financial specialist who will give you a price
quote for the whole package (Pre-operative, operative, and
post-operative care). Payment by Visa and MasterCard is also
If you think your plan provides you with "out of network"
benefits, you may still be able to meet with one of the surgeons
according to the terms of those benefits. For questions as
to whether or not you have "out of network" benefits,
please call the member services number on the back of your
insurance card. Please note that all patients coming to us
from out of network must pay the surgeon's fee in full prior
to the date of surgery.
Things You Can Do To Help Yourself
These are some of the things that you can do prior to your
first visit to help things run more smoothly.
- Know your insurance company
- Read your policy
- Call your representative
- Bring in your insurance card with policy# and address
Gather your medical records
Medical records that document any co-morbid conditions (diabetes,
sleep apnea, hypertension, hyperlipidemia (high cholesterol),
heart disease, acid reflux, arthritis, etc
Document medically supervised weight loss attempts (Jenny
Craig, Weight Watchers.)
Keep a dietary log
Keep track of every single thing that you eat or drink for
2 weeks prior to your initial consultation visit.
Finally, it is important to note that while we do try to
anticipate the needs of the various insurance companies, pre-authorization
can never be guaranteed nor is it a guarantee of payment in
full. However, are fully committed to working with you, your
physicians and your insurance company to ensure success in
every aspect of attaining your weight loss goals.
Insurance Related News:
Health insurers backing off obesity surgeries
By Christopher Snowbeck, Pittsburgh Post-Gazette
Health insurers, seeking to control overall costs, are trying to tip the financial scales by dropping coverage for popular but expensive obesity surgeries.
The moves respond to the increased use of gastric bypass procedures, which have been championed by celebrities and could swell the overall number of obesity surgeries in the country this year to 200,000. At a cost of about $25,000 each in simple cases -- and much more in complicated ones -- health plans say the costs have driven up premiums so much that their customers just can't afford it.
"Many employers are finding it difficult to provide health insurance at all these days," said Susan Pisano, spokeswoman for America's Health Insurance Plans, the trade group for health insurers. "What they see in gastric bypass surgery is a procedure that's being overused, and that's driving their health care costs up, so they face a dilemma."
But doctors counter that there is no overuse, just a growing recognition of the surgery's benefit. They say the procedures are clearly necessary for some morbidly obese patients, for whom dieting isn't a solution.
"If you speak to the world experts on the best available behavioral, diet and lifestyle interventions, they will tell you they are not successful long-term for people who have more than 100 pounds to lose," said Dr. Anita P. Courcoulas, director of bariatric surgery at the University of Pittsburgh Medical Center. "There's good data out there that shows for 60 percent to 80 percent of patients who have this surgery, their long-term health is markedly improved."
A 2004 report from the Pennsylvania Health Care Cost Containment Council found that 6,791 gastric bypass surgeries were performed in the state in 2003, up ten-fold from 1999 when only 674 were performed. Between 1999 and 2003, the number of surgeons performing gastric bypass surgery increased from 31 to 84, the council reported, and the number of facilities increased from 26 to 49.
In the face of the increase, HealthAmerica has decided that, effective June 1, groups renewing their health benefits with the insurer no longer will receive obesity surgery coverage in their basic medical plan. Firms with more than 250 employees can obtain coverage if they purchase a rider for obesity surgery.
HealthAmerica's move follows similar steps taken by national insurers Aetna and Cigna.
Locally, Highmark and UPMC Health Plan continue to include gastric bypass surgery in basic health insurance coverage. But the number of surgeries covered by Highmark dropped during 2004 after the insurer tightened the criteria for patients seeking operations.
Robert L. Dawson, HealthAmerica's president and chief executive officer, said the company believes the surgery is "an extraordinary risk to take," particularly if patients don't also address the underlying diet and lifestyle issues involved with obesity.
But cost is a factor, too. "Coverage for obesity surgery benefits a small number of people at a cost that is incurred by all our members and their employers," a March 15 letter from HealthAmerica explaining the change said.But many of those patients who need the procedure will struggle to pay for it out-of-pocket, said Dr. Nilesh Patel, a bariatric surgeon at Allegheny General Hospital. Obesity is a socially acceptable prejudice, Patel said, and society has no sympathy for fat people, saying it is a self-inflicted problem.
Courcoulas, the UPMC surgeon, said the risks of illness and death following obesity surgeries are no greater than with any other complex abdominal operations. While there are significant up-front costs with the procedures, Courcoulas argued that health plans would recoup their investments in about three years as post-surgery patients avoid other health problems.
Some insurers, including Highmark, now require supervised diet therapy prior to surgery. Dr. Martin Fenster, Highmark's medical director for utilization management, said he agreed that dieting along isn't a long-term solution for many patients. Even so, patients after surgery must make lifestyle changes so they don't regain the weight, Fenster said, and might as well develop the habits beforehand.
Highmark's restrictions drastically cut the number of covered surgeries from more than 3,000 in 2003 to less than 2,000 in 2004. Even so, the rate of surgeries in the region still exceeds the national average, Fenster said.
Some of the quality problems have simply been a function of surgeons learning how to do gastric bypass surgeries laparoscopically. Gastric bypass surgeries performed through large, open incisions have been around since the 1960s, but were never as popular.
"You have a lot of doctors on the learning curve, and everybody wants to get in on the learning curve," Fenster said.
If all the recent news about insurers clamping down on obesity surgery is casting a pall on this week's annual meeting of the American Society of Bariatric Surgery, Barbara Thompson hasn't noticed. The Upper St. Clair resident, who underwent obesity surgery more than 5 years ago and sings its praises, is attending the meeting in Orlando, Fla.
"I'm optimistic," Thompson said, noting that Medicare was asked this year to consider expanding coverage of gastric bypass to patients who are just obese -- as opposed to those who have certain related health problems.
"The surgery just gives you tremendous freedom," said Thompson, who has published books on the subject. "It's improved my health, my life, my self-esteem, my ability to live life fully."