There are several weight loss surgery insurance secrets that can save you money, time or even get coverage added to your plan. Following is an updated list of the lesser known truths we’ve gathered over the years.
Continue reading to learn more about weight loss surgery insurance secrets.
TABLE OF CONTENTS
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- You should start working with a surgeon early in the process
- Ask them to do all the legwork for you (for free)
Even if bariatric surgery is covered by your plan (see our Bariatric Surgery Insurance: Complete Patient Guide for plan-specific coverage criteria), there’s no guarantee that you’ll get approved – even if you meet the weight and health requirements.
For example, most insurance companies require the following for adults prior to approving surgery, many of which must be submitted in a very particular, insurance-company-specific way:
- BMI (body mass index) above 35 with obesity-related health problems (or BMI above 40 without health problems)
- Participation in a "clinically supervised" weight management program
- Letter of Medical Necessity
- A recommendation from a doctor other than your surgeon
- Medical clearance
- Clearance for surgery from a mental health physician
- Nutritional evaluation from a Registered Dietitian
- Coordination with an insurance company Medical Case Manager
That’s a lot for you to deal with on your own.
What’s worse, if you get anything wrong and your insurance denies your coverage as a result, the process to get that denial reversed can take months.
So here’s the secret: Most bariatric surgeons will hold your hand through the entire process as part of their standard service. They’ll even contact your insurance company for free to confirm your coverage even if you haven’t yet decided to move forward with surgery.
They have probably worked directly with your insurance company for hundreds of patients, and they’ll know what it takes to get surgery approved.
Bottom line: Instead of starting the process on your own, contact a local surgeon from the outset.
- You can get most of the pre-op services paid for
If you have insurance but it doesn’t cover bariatric surgery, you’ll probably be able to get some of your expenses covered.
According to several surgical practices we interviewed during our Annual Weight Loss Surgery Cost Survey, it’s all about how your doctor and hospital submit your claims to your insurance company. As long as your doctor files the claim using a covered "CPT Code" (Current Procedural Terminology Code), then your insurance company will likely cover it as long as the code used accurately reflects the treatment provided.
For example, there are many non-bariatric surgery reasons for your doctor to recommend:
- Lab work
- Psychological exam
- Cardiology exam
- Sleep study
- Medically supervised diet program
Regardless of who pays, each of these are also essential steps required before your surgeon will perform your surgery.
If your surgeon or primary care physician submits the above claims using a weight loss surgery CPT code, your insurance is unlikely to cover it.
However, if your doctor submits the above claims using a NON-weight loss surgery CPT code, the claims will likely be considered covered benefits.
While this may sound "sneaky", in actuality it is a very ethical practice. Services like those listed above are performed as a result of an existing medical condition… some are exploratory and intended to accurately diagnose the patient, others are treatments intended to improve the patient’s health.
Whether or not they are ultimately used to facilitate weight loss surgery is irrelevant. In other words, the results of any of this work will be beneficial to the patient regardless of whether or not the patient is interested in obesity surgery.
- Medical tax deductions
- BLIS protection
- Self-pay & other discounts
- Shop different hospitals with the same surgeon
Even if your insurance covers weight loss surgery, you’re still likely to have out of pocket costs in the form of deductibles, copays and co-insurance amounts. Following are several weight loss surgery insurance secrets that will help to get those costs down…
- Medical tax deductions: The IRS allows you to deduct your medical expenses as long your costs are higher than 10% of your adjusted gross income. Click here for the details.
- BLIS Protection: The risk of dying from surgery is extremely low, but complications resulting from surgery can and do occur. BLIS, a relatively new form of insurance protection offered directly to surgeons, will pay for the cost of any complications that arise as a result of surgery. This kind of protection can reduce costs for both you and your surgeon should any complications arise.
- Self-Pay Discounts – If you don’t have insurance or insurance won’t cover your surgery, most weight loss surgery programs will offer some sort of self-pay discount or payment plan. Just ask! Click here for additional bariatric surgery financing options.
- Other Discounts – Some practices offer additional discounts if you pay the total amount you owe in advance.
- Same Surgeon, Different Hospitals – Some surgeons can choose between two or more hospitals for the actual procedure to take place. Hospital charges make up the largest portion of the total bariatric surgery bill by far, so ask your
surgeon’s office if they have operating privileges at more than one hospital and, if so, which is the less expensive option.
For example, one office we contacted in our annual surgeon cost survey quoted a difference of more than $10,000 between hospitals.
The hospital where the procedure is performed does NOT change where your pre-op and post-op visits will take place, only where your actual surgery is performed.
- A surgeon can be added within a few months
Insurance companies will pay a much lower percentage of your costs if you choose a non-network surgeon, so it’s worth the extra effort to get your surgeon added before moving forward with surgery.
Contact your insurance company and tell them that your doctor is not in their network and that you would like to get them added. They will let you know the steps necessary to get the surgeon credentialed, approved and added.
Expeditious insurance companies can usually complete this process within 2 to 3 months. If you have trouble handling this directly, contact your Human Resources department for assistance.
- The Affordable Care Act (Obamacare) requires insurance coverage for weight loss surgery in almost half of all states
Many Americans don’t realize that Obamacare (technically called the Affordable Care Act) REQUIRES insurance companies in many states to include bariatric surgery in ALL Individual, Family and Small Group plans (insurance plans for companies with 50 or fewer full-time employees).
See our Obamacare Weight Loss Surgery page for the updated details.
- You should make the business case to your Human Resources Department
If you work for a company with 51 or more full-time employees and your plan does not currently cover bariatric surgery, you may be able to convince your employer to add it.
Your first step is to go to Human Resources (HR) and present your case. The only way HR is going to get senior management to add bariatric surgery is if HR can present a compelling business reason to do so.
The trick to presenting a compelling business case to HR is to take all emotions out of the discussion. You should focus strictly on how adding bariatric surgery is a good business decision and will improve your company’s bottom line (how much money they make).
We have good news…
In addition to providing you and others with a benefit that will improve your health and extend your life, adding bariatric surgery to your plan is an extremely good business decision.
To help your Human Resources department understand why, either:
- Refer your HR representative to the section below ("4 Business Reasons to Add Bariatric Surgery to Your Company’s Health Insurance Plan")
- Print and present the following section along with this page (click link to open pdf document) on your own.
4 Business Reasons to Add Bariatric Surgery to Your Company’s Health Insurance Plan
For no extra charge, a good employee benefits broker or consultant should be able to do all of the legwork (including presenting the results to Finance) surrounding bariatric surgery and determine how adding it to your plan would impact your company.
Case Study: Hawaii Pacific Health
Hawaii Pacific Health (HPH) was one of the first employers in the country to cover weight loss surgery under their wellness program, and their program fully reimburses qualified employees for all expenses.
Gail Lerch, HPH’s executive vice president of human resources, made the recommendation to add bariatric surgery because she felt that not to add it "will cost us far more in medications and lost attendance for our employees, who we are helping to make changes in their life."
Click here for the full story.
In most cases, you will find that adding weight loss surgery will reduce your overall health care costs and increase the productivity of your morbidly obese employees.
Following are the research-supported reasons to add bariatric surgery to your plan:
1. Direct Financial Benefit
According to the American Journal of Managed Care (AJMC) (1), an investment in bariatric surgery will break even within 2 years for laparoscopic surgery and within 4 years for open surgery (about 80% of bariatric procedures are laparoscopic).
Click here to see how The HR Capitalist views this data.
In addition, most major insurance companies have determined that bariatric procedures like the gastric sleeve or gastric bypass eliminates or improves obesity health problems to the extent that they have agreed to offer coverage as an option. And several states actually require that it be included. Table 2 of the AJMC study shows that following 13 months after surgery, patients saved over $900 per month compared to those who did not receive it (2).
A Duke University Medical Center study (3) also found that obese workers file twice as many workers compensation claims and have 7 times higher medical costs than non-obese workers.
2. Indirect Financial Benefit
The same Duke study referenced above found that obese employees lose 13 more days on average when they suffer a work injury (4).
A Journal of Occupational and Environmental Medicine (JOEM) study also concluded that moderately to extremely obese workers experienced a 4.2% health-related loss in productivity compared to 3.02% for everyone else. This 1.18% difference equated to $506 per worker annually (5).
In addition to confirming health care cost differences, a study posted by the National Center for Biotechnology Information (NCBI) found that severe and morbidly obese workers had 57% more annual sick days than their non-obese counterparts (6).
3. Legal Considerations
There are situations where you may be legally required to pay for weight loss surgery. In Boston’s Gourmet Pizza v. Adam Childers, for example, an Indiana court ruled that the employer must pay for bariatric surgery as a precursor to treating a work-related back injury (7). Adding it to your health plan now could prevent future legal issues and the added expense of paying for surgery on a “one-off” basis.
4. Is your health insurance plan self-funded?
If so, the long-term cost savings of bariatric surgery will be much more apparent. If you are unsuccessful in getting surgery added to your plan, do your company’s policies allow the use of your “ex-gratia” plan provision? In other words, could your company agree to pay for the surgery on a one-off basis outside of the scope of your stop loss agreements for the employee who asked that you consider adding bariatric surgery?
We have prepared a series of questions and a sample scenario that will help you or your broker/consultant determine whether bariatric surgery is a good business decision for your company. Click here to open the pdf file.
- You may be able to receive benefits during your recovery
Disability insurance (DI) pays you a percentage of your monthly income if you are unable to work. Short term disability insurance (STD) most commonly pays 66 2/3% of your salary for the first 90 or 180 days of disability or sickness (also known as your disability period for bariatric surgery).
Unfortunately, it is usually only available through an employer, although you can continue coverage as an individual if you leave the company.
Just like health insurance, disability insurance includes pre-existing conditions limitations. In other words, insurance companies won’t let you buy coverage one month and go out on disability the next for something that you knew about before you signed up.
The best way to get around this for bariatric surgery is to enroll with your employer during the initial enrollment period (i.e. when you’re hired). You may not be allowed to enroll at any other time.
You must then remain enrolled for the entire “pre-existing conditions exclusionary period,” which usually lasts between 6 and 12 months. Call your insurance company, talk with HR or review your plan documents for details.
- You can ask a local bariatric practice for a free insurance check or cost quote
- You can attend a free in-person seminar or an online webinar offered by a local weight loss surgeon
- You should schedule a phone or in-person consultation (both often free), if you are interested in learning more about weight loss surgery
Search the weight loss surgeon directory below to find a weight loss surgeon by country and region: