Insurance information
Finding out whether or not surgery will be covered is critical before formal enrollment into the program. The following are general guidelines:
Medicare
Medicare currently covers the Lap Band ® and the gastric bypass with no pre-certification is necessary. However Medicare does not give prior approval for surgery, so a denial is still possible before and after surgery.
Medicaid
We accept Medicaid from Massachusetts but not from other states. A very rigorous set of guidelines must be met for patients to qualify for gastric bypass. The Lap Band ® procedure is not yet covered by Medicaid. Specifically, patients must have documentation of recent physician-supervised weight loss attempts.
Private Insurance
Insurance coverage for weight-loss surgery varies depending on the individual patient's insurance plan. Gastric bypass and Lap Band ® surgery is a covered benefit by many insurance companies, depending upon the type of policy you have and its terms. Insurance policies vary even though they may have been issued by the same insurance company.
Patients are advised to review their individual insurance policies to understand what insurance benefits are covered. This clinic's policy is to utilize NIH criteria; however, specific guidelines required by insurance companies for coverage of gastric bypass surgery may not correspond exactly. Financial counseling and pre-authorization from insurance companies needs to be secured before surgery can be performed.
Self-Pay (no insurance coverage)
Some patients may choose to pay for the surgery on a self-pay basis. These arrangements can be made by speaking directly with the surgeons administrative assistants. There are three procedure fees to consider, the physicians, your hospital stay, and for the anesthesia totaling approximately $30,000.
Insurance Denials
If you receive a denial of insurance coverage by your insurance company, you should not consider this to be a “definite no.” In many cases, providing additional detailed information, in the form of an appeal letter, will result in a denial being overturned. If your insurance carrier remains unreasonable, you may want to consider writing your legislator or seeking legal assistance. Legal assistance can be obtained through a local attorney, via www.obesitylaw.com.
