Insurance coverage is one of the most asked about topics when it comes to bariatric surgery. Patients are often surprised to learn that weight loss surgery is a covered benefit under many insurance policies. But coverage does not necessarily mean no cost to the patient or that you can have surgery tomorrow. Many factors come into play when determining what your cost for surgery might be, when all is said and done. Our team will work with you to help you navigate this process, but we always encourage patients to become familiar with their policy, as ultimately, it is the responsibility of the patient. From obesity coverage to your tailored surgery estimate, our team will be with you every step of the way to help you feel comfortable with the financial side of weight loss surgery.
Coverage for Obesity Treatment
Insurance coverage is typically built around a few concepts, but it can be get confusing. The first is covered services. Your policy may cover many medical treatments and services while others are excluded. The first step in pursuing bariatric surgery through your insurance is verifying that you have coverage for obesity treatment. We do this by asking your insurance provider about coverage for ICD10 code “E66.01.” An ICD10 code is simply the label for a diagnosis; “E66.01” is the diagnosis of obesity. If you are at a point where you have chosen your procedure, you can go on to ask about the specific surgery coverage. For this you will need procedure codes called CPT codes. Once a plan is established with your surgeon, our team can share the specific CPT code for your procedure, and you can double check your insurance plan.
Some policies have specific exclusions for bariatric surgery. If this is the case, you have a few things to consider. First, is there a policy with coverage for weight loss surgery you could opt for? Check your spouse’s coverage, if different than your own, for coverage and consider if a switch may be worth it. Second, often bariatric exclusions are decisions made by a company’s Human Resources department. Consider meeting with the HR Officer to discuss the coverage and see if a change in coverage is in the works for the upcoming year. Last consider self-pay options. For some patients, coverage is simply not an option, so we have carefully negotiated self-pay rates for patients who wish to pay directly for their procedures. We include every expense we can in this self-pay rate to help you have a clear idea of the fees involved. Third party financing may be an option as well – borrowing funds.
Breakdown of Your Responsibility vs. Your Insurance Company’s Responsibility
Most often policies include factors like deductibles, out of pocket maxes, and/or copays. These are terms that break down who owes what, and at what point your insurance company pays and what amount.
A deductible refers to an amount of money that the insured individual must pay before your insurance company will pay a claim. Deductibles vary from plan to plan. Your insurance card may have the amount broken down on the card itself, it may reference a website you can visit, or a phone number you can call for more information. As you pay for some medical expenses, you contribute to your deductible amount. Once your deductible is met, the policy starts to pay, in some way or another. It should be noted, some services do not apply to the deductible, this is something you will want to research or discuss with your insurance provider and understand.
Coinsurance refers to a split of expenses between the insured and the insurance company. This may be something like 80/20 where your insurance company pays 80% of a covered service and you pay the remaining 20%. Some policies look more like 50/50. With some policies, a deductible must be met first, while others only pay coinsurance.
Other policies may have only a copay. Typically copays vary depending on the type of service and location of service. You may pay one amount to see your primary care provider and another to visit a specialist. You may similarly have a set copay amount you will pay for surgery based on the facility and surgeon performing the service.
Out of Pocket Maximum
Generally, patients will have an out of pocket maximum, or OOP Max. This can be either as an individual, family, or both. This means once you have paid your portion of expenses totaling to the max amount, covered services are reimbursed at 100%.
Using the factors we discussed above, our team will compile an estimate for surgery. This will factor in details like your chosen procedure, the facility, your chosen surgeon and your current standing with any deductible and out of pocket amount accumulated. Some providers and facilities are considered to be in or out of network. In this case, the coverage may pay out differently. While we use all of the information possible to best determine and help you understand your responsibility for surgery, it is always wise to do your own research as well. Typically, facility fees and anesthesia fees will be billed separately by the entities that provide these services, not by our practice.
These estimates may also change as your go through your pre-operative work up, which often requires tests and appointments. If you are nearing your deductible or OOP Max, we will keep a close eye on things, especially when we know other claims are pending or will be submitted. Oftentimes claims take time to process and you may know your deductible is met before your insurance company has updated its information. Also, it is important to keep in mind that many people are meeting their deductible toward the end of the year and would like surgery before their deductible rolls over with the New Year. This increased end of year volume can create a traffic jam of sorts for insurance companies and turn around time can be slowed.
It is typical for insurance companies, whether commercial policies or government sponsored, to have a set of specific guidelines for procedure coverage. It is in your best interest to understand the guidelines put forth by your specific policy and do your homework to make sure you meet the criteria set forth. Your coverage may require that you document a year of participating in a physician supervised weight loss program or that you have ruled out certain conditions that could contribute to weight gain. It could also be that a letter of support is required from your primary care provider. Some policies require certain tests or additional pre-op appointments to be completed before surgery as well.
With most policies, it is possible to submit a case for review by the insurance company prior to surgery through a process called prior authorization. During this process, our team is reviewing your case based on policy guidelines and then your insurance company’s team also reviews the case. This process gives us the best possible indication of coverage approval for your actual surgery. However, prior authorization is not a guarantee of coverage.
Our team of surgeons at MASJax is supported by an incredible staff who will help you understand and guide you through this complex process. If you think weight loss surgery is the right choice for you, we invite you to learn more about your options and get started on your journey through a bariatric seminar. If you have questions about your coverage for surgery, our staff will be delighted to help.