Insurance Denied My Weight Loss Surgery – Now What?
September 12, 2014Receiving an insurance denial for weight loss surgery can be upsetting news for many patients. Often patients have invested months into preparation for the chance to have life changing and saving surgery only to receive a big "no". However, a denial does not mean all hope is gone. While the reasons for denials vary, here are several options to take the next step in your journey.
- Reason for Denial - The first thing to do is find out the reason the insurance company denied your surgery. The denial notification should be provided in writing stating the reason. If not mentioned with details, request more information, also request the guidelines and specific policy used to make the determination.
- Administrative Errors - Often denials are due to administrative errors such as not all information was received, or the wrong code was submitted. Administrative issues are relatively easy to resolve once the error is found. You would need to find out what information is missing and have the surgeon's office resubmit. If the information comes from other doctors, you might need to request records be resent.
- Peer-to-Peer Review - If all information was correctly submitted and received, and you have the reason for the denial, the next step is to have your surgeon do a Peer-to-Peer review where they schedule a time to call the insurance company to discuss the medical necessity of your surgery. Often the additional information or explanation your surgeon provides during the review can get the denial reversed and surgery approved. If not, it will at least provide further insight into why surgery was denied.
- Appeal - Read your insurance's process for appeals, it should be outlined in the denial letter. Before submitting your appeal materials be sure you have all coverage information, policy guidelines for the treatment of obesity, and the reason for which you were denied. Again, the insurance company must provide you with both. Some surgeons offices may assist with appealing the denial, others may leave the entire process to the patient to manage. There are several levels to the appeals process, it may take more than one appeal to overturn a denial. Appeals are time sensitive, be aware of the deadline for which you must file your appeal.
- Change Plans - While there are no guarantees a policy will approve coverage for weight loss surgery, if your denial is because of an exclusion, you may want to explore other insurance plan options. For example, some employers might offer weight loss surgery coverage under a PPO plan but not the HMO option. Switching plans can only take place during open enrollment, the only exception is if you experience a qualified life event.
- Self-pay Options - The risk to self-pay is that is that most insurance companies will not cover any complications that may arise from procedures they did not initially cover. There are supplemental complication insurances available, ask your surgeon about your risk for complications and if their office offers supplemental complication insurance.
- Finance - There are many healthcare credit companies that offer financing for medical purposes. Often you have to find a physician that participates with these companies. Interest rates and repayment options vary.
- Retirement - Some retirement plans allow for loans and/or withdraws for medical reasons. While an option, one must research and educated themselves on all possible penalties and taxes that must be paid when withdrawing funds from retirement plans. Loans from retirement, if available, offer easier access to funds but repayment is required.
- Medical Travel Tourism - Traveling out of the country for surgery is an option many patients make. As with any surgery and/or travel, one should research the doctor, facility, and aftercare. Also remember to make arrangements for care and follow-up once you return home.
Disclaimer - This article is not meant to provide medical, legal or financial advice. Consult with appropriate professionals before making any decisions.
Photo: Nathan Gibbs cc
 | ABOUT THE AUTHOR Sarah (aka Sarahlicious) has been an active member of ObesityHelp since 2003. Her specific areas of interests are Lipedema, Lymphedema, Obesity, and Health Insurance advocacy. Sarah writes about her life experiences at Born2lbFat. She is a member of the Board of Directors of both the Obesity Action Coalition and the Lymphedema Advocacy Group. Sarah has a Masters in Health Law.Read more articles by Sarah Bramblette! |
