Hap insurance

I have HAP HMO through my employer Henry Ford Hospital. I called the client service number to inquire about the coverage for Bariatric surgery. They said that the doctor has to determine that it is medically necessary and I have to pay a 1000 dollar copayment which is no problem for me. Has this been the case for anyone who has this insurance? If the doctor determines that its medically necessary for the surgery, does the insurance company have to approve it?

Usually, an insurance company is not constrained by the orders of a doctor.  That is why doctors must submit medical information to the insurance company to seek approval.  The insurance company enlists a gaggle of people (e.g. pre-certification specialsts, claims professionals, nurses, doctors, etc.) scrutinize the sent information to ensure that it meets certain guidelines for coverage.

However, I believe your case may be different, just based on your employer.  If you work with a hospital, chances are that your employer will be self-funded and will constrain you to visit the physicians it employs or physicians who have a relationship with your employer.  The doctors you visit, who are probably co-workers, will know the intimate workings of your medical plan and will know what will be covered and what will not be covered.  In that sense, then the insurance company (most likely your employer) will be constrained to what the doctor says.  In the cases of people who do not work with hospital or medical groups, there are no such constrictions put on the insurance company.

I hope I was able to answer your question appropriately.

X-man

Thank you for the information, Xavier. I really appreciate it.