Choosing Your Strategy for WLS Coverage
At this point, you've called your insurance plan with the detailed list of questions from the previous section. Now what? You can also find more information about insurance coverage and denials in the Insurance Help Forum.
As a first step, you might want to compare what you have been told with experiences that your peers might have had with the same insurer. Check the insurance directory on this site. Most of the people with the health plans listed had experiences which were strongly shaped by who their employer was, so if someone with your same type of insurance (same company, same plan) had one outcome, your outcome might be completely different if your employer is different. Perhaps your research will lead you to peers who have had the same employer. In any case, a better understanding of your carrier's past performance will help you gauge your expectations.
What next? The first thing to consider is what to do if you learn that your insurer doesn't cover bariatric surgery at all. Typically, you might learn that they have a “written exclusion policy.” If you don't, then skip to the following section
What to do if you have a written exclusion policy
If your insurer does not cover bariatric surgery, there are several things you can do. First of all, you could consider getting an additional add-on policy that will cover your surgery. An example is Anthem insurance. Premiums may be very high, but depending upon what plan you are able to get, you could come out ahead overall.
Another option is for you to wait for the opportunity to get a better health plan. This might mean waiting until open enrollment at your employer or your spouse's employer, at which point you might upgrade from an HMO to a PPO. Or, it might mean changing employers.
Proceed with the battle
Another option is to proceed with the entire process outlined hereafter as if you didn't have an exclusion policy and simply plan ahead for a fight. You will generate all the same paperwork documenting medical necessity, send in your packet, wait for your denial, and have a well-prepared appeal letter ready to be mailed as soon as you receive your denial. When your appeal is denied, your second appeal is ready to go. Along the way, you may contact attorney general's offices or legal counsel which, together with strong backing from your primary care physician, will give you a shot at approval. Check the insurance directory for people having had surgery approved after a first or second denial.
Cash and financing
A final option (which you can do along the last one) is to simply expect to self-finance your surgery with cash. Bariatric surgery is a life-transforming change affecting the rest of your life. Unless your health is rapidly deteriorating, you might save yourself a great deal of emotional turmoil by taking the time to save up for surgery. Depending upon how much money can be borrowed from other sources, this could take a year or several. Note, though, that financing is available for the procedure. Hospitals and surgeons around the country often offer special cash rates to people without insurance. Through saving, borrowing, and institutional financing, bariatric surgery is as within reach as a $20,000 automobile might be. Insurance might or might not be of help to you. It shouldn't, however, by any means have any final say in what you do with your life.
It looks like I'm covered — what next?
First of all, consider applying in advance for financing. Doing so is usually free. If you wind up not being approved, you will be able to go through the appeal process with the peace of mind that, worst case, you have other options arranged. It's your life and you should control the process.
Based upon your call to your insurer, you should know which surgeon or surgeons you are covered under your plan. Go head and make an appointment to see the surgeon. If you have a choice of more than one surgeon, go head and make appointments with several to get your foot in the door. Waiting lists for initial consults with surgeons may run into months. Some surgeon's offices may require a referral from a primary care physician. If so, this can often be presented by fax up to the day of your visit. Get your appointments early. While waiting, take the time to get to know patients of surgeons you are considering to help you make your final decision.
Note, in many cases your decision might be limited by surgery types performed. Some insurers may cover RNY but not DS. Perhaps you feel that a laparoscopic procedure is very important to you but not covered by your plan. You will need to match these constraints with surgeon availability. Sometimes deciding which surgeon, which surgery type, and whether the surgery is open or laparoscopic will all be linked to each other based upon a combination of insurance requirements and surgeon availability. Now is the time to weigh all these factors along with those you started learning about in the “selecting a surgeon” section earlier.
If you are needing additional assistance in finding a surgeon in your area please contact us Monday-Friday 9am-5pm PST 1-866-297-4964
I've picked my likely surgeon or surgeons. What do I do now?
At this point, you can chose to sit back and wait for the surgeon's office to handle everything for you. Bariatric centers may often guide you through the entire process, beginning with instructions on how to proceed with your insurer (which you've already done by now if you are following our outline) and your primary care physician.
An alternative to this is to play a more active role in getting your authorization. If you take this route, you might save yourself a great deal of time and are likely to be much better informed about your situation. Resources and peers in our community are here to guide and assist you.
Taking this route, you need to do whatever is necessary to obtain a letter of medical necessity with supporting documentation from a dietician and a psychologist, whose report is referred to in the industry as a “psych eval.”
Question: Did your insurer say that the letter of medical necessity had to come from the surgeon? If so, then follow the following sections but leave that part to the surgeon. Otherwise, plan on having your primary care physician sign a letter of medical necessity for you.
Question: Does your insurer reimburse you for a visit to a dietician and psychologist without your needing a referral from your primary care physician? If so, then schedule an appointment with these professionals as soon as possible. If not, then you'll need to see your PCP first, which might slow you down a bit. In either case, you will probably need to educate your PCP about bariatric surgery. In some cases, you might want and be able to shop around for a PCP who is known to be supportive of bariatric surgery.
To facilitate interactions with your future surgeon, you may wish to select the same dietician and psychologist that they use. Alternatively, if the wait list is too long for those professionals, you might decide to select alternatives.
By the time of your initial consult with your surgeon, many weeks may have passed since you first made your appointment. By that time you may have your authorization already in hand. Alternatively, you might have completed some but not all of the steps required.
So the bottom line is that before beginning any work you should carefully map out your plan of attack. Your style might be active or more passive; enthusiastic and self directed, or perhaps more laid back. Understand the requirements of your health plan before proceeding. If you are uncertain of these, contact your insurer for clarification. Find resources to help you on this site.
You're in control.
Map your preferred path as well as your backup paths. You may not be able to predict how or when, but if you believe that bariatric surgery is for you, you'll get there.