Calling your health plan
Objective
Collect information from your insurer to determine what your plan of action will be.
Before calling
- Carefully research and select a number of bariatric surgeons you are interested in.
- For each surgeon, check our site to see if information is available about what dietician
and psychologist that surgeon usually sends his or her patients to.
- Start a folder to contain paperwork for all your insurance dealings and
be ready to take notes from your call for safe keeping here.
Your Call
- When you get through to a service representative at your health plan,
record the name of the person you speak with. Record the date and the time
of the conversation. Take good notes.
- Ask your insurer what policy they have on specific CPT codes. Health
plans approve medical procedures based on diagnosis codes. The diagnosis
code for morbid obesity is 278.01. Procedures are coded by the medical
industry with things called CPT Codes. Bariatric surgery can encompass
several CPT codes, depending upon which procedure type is used. Below is a
list of CPT codes. For each code, ask what their reimbursement policy is.
The usual response for each is 'approved if medically necessary'. See if
they tell you that. Another possibility is that they have what is called a
'written exclusion policy'. In either case, carefully record what they say
for each code.
| CPT Codes |
|---|
| 43846 | Short limb RNY |
| 43847 | Long limb RNY |
| 43659 | Laparoscopic |
| 43847 | Duodenal Switch |
| 47600 | Duodenal Switch Related |
| 43633 | Duodenal Switch Related |
- Find out which surgeons your heath plan reimburses for. A simple way to
do this is to ask them what surgeon you would need to use to have any of
the procedures above performed. It is possible that they may tell you. More
likely, you will need to provide them with the names of surgeons you have
researched and they will tell you if each surgeon is in or out of network.
- Ask about reimbursement amounts & alternatives. Depending upon your plan
type, you might be covered for only one surgeon and receive no insurance
coverage for anyone else. Alternatively, you might have a small co-payment
with one or more surgeons but still have coverage but with a much larger
co-payment for any other surgeon. Carefully record your options.
- Repeat the above two steps for a) dieticians and b) psychologists. Most
health plans will not approve surgery unless a patient has a letter from a
dietician and also a psych evaluation from the psychologist (or
psychiatrist). They use the latter to help identify individuals at high
risk for postoperative failure.
- Confirm referral requirements. Are you able to schedule an appointment
with a dietician and a psychologist yourself directly? Or, do you need to
be referred to them by your primary care physician? Also, ask to confirm
whether you need a formal referral from the primary care physician in order
to see a specific bariatric surgeon.
- Ask about the letter of medical necessity. Health plans rarely
authorize coverage for bariatric surgery without something called a letter
of medical necessity. This letter explains why surgery is a non-cosmetic,
life-saving procedure. It is usually written by the bariatric surgeon. Ask
your insurer if it has any policy stating if the letter must come from the
surgeon, or if on the other hand it would accept one from the primary care
physician as well.
- Before hanging up, make sure you've recorded all the information above
on paper and asked for clarification on any questions you had.
» Next step: Choosing your strategy
