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Weight Loss Surgery Program

Insurance & Financing

Verify Insurance Coverage

Before you consider weight loss surgery, YOU MUST contact your insurance company to verify that weight loss surgery is covered by your policy and that MUSC is recognized as a provider by your insurance company. Some policies exclude all types of weight loss surgery. If there is no specific exclusion, a representative of the insurance company is generally contacted to verify whether the benefit is actually available.

One important point to keep in mind is that obesity and morbid obesity are considered 2 different health conditions. Many plans will exclude treatment for obesity but will cover treatment for morbid obesity.

Another important point to keep in mind is that not all representatives of a particular insurance company will be as knowledgeable about their policies as others. Some will not even know what morbid obesity is and you may be misinformed about coverage. It is important to check more than one source to verify that what you have been told is valid.

One important point to keep in mind is that obesity and morbid obesity are considered two different health conditions. Many plans will exclude treatment for obesity but will cover treatment for morbid obesity. It is important to be very specific in the language you use when dealing with insurance companies. Another important point to keep in mind is that not all representatives of a particular insurance company will be as knowledgeable about their policies as others. Check more than one source to verify that what has been told to you is valid.

Benefit Guidelines

Many insurance companies have their own specific benefit guidelines, describing whether treatment for morbid obesity will or will not be covered. If it is a covered benefit, they have specific requirements that must be met before they will authorize benefits for the treatment. The process can be long and difficult requiring much effort on the part of the patient and the doctor’s office.

Explanation of Common Requirements

The following is a basic list of what insurance companies may require in order to determine if treatment for morbid obesity is a covered benefit.
*Please note that we will not begin the pre-certification process until you have provided our office with all the required information:

  • Documentation of Dieting

    • Most insurance companies are asking for documentation of a physician directed weight loss program. We will need any and all medical records from your primary care provider. Most insurance companies that require adherence to a physician directed weight loss program are requiring documentation of at least 3-6 months in the past 12-24 months. This may include monthly documentation from your physician. Verify with your insurance company the specific requirements.
  • Psychological Evaluation

    • Insurance companies require a psychological evaluation. You will receive a comprehensive evaluation to assist in the identification of psychosocial strengths and weaknesses that may potentially affect bariatric surgery outcomes. You will be evaluated by our team of clinical psychologists before having surgery. If you are currently under the care of a counselor, psychiatrist, or psychologist, we ask that you obtain a letter of support from them.
  • Medical Records

    • Medical records are required and must be submitted with all other documentation prior to the insurance company making a determination and approval for your surgery. Please provide us with your primary care provider’s medical records for the last five years. This will help us to document your ongoing problem with morbid obesity, as well as documentation of all treatments and interventions required for co-morbidities (i.e. diabetes, hypertension, etc).
  • Letter of Medical Necessity

    • This is a letter usually written by your surgeon that outlines your medical, diet and exercise history and your current state of health. It is the summary of all your information that makes the case for why surgical treatment for your morbid obesity is medically necessary. This letter is usually submitted with all your other documentation.
    • Some insurance companies also require a letter of medical necessity from your primary care provider as well. It is important that you verify with your insurance company what they require for approval of surgery.
  • Predetermination

    • Once all your records are gathered and sent to the insurance company with the letter of medical necessity, the insurance company goes through a review process to determine if they will approve this benefit for you. At this point they may ask for more documentation, approve this benefit for you or deny this benefit to you. If you are denied, most insurance companies have up to 3 appeals that they allow you to make.
    • Make sure all documentation is complete prior to filing an appeal. It is also important not to be discouraged during the appeals process as many initial denial decisions are overturned in later appeals. It is your responsibility to make the appeals. We are happy to help guide you through this process.
  • Pre-certification

    • If your benefits for treatment have been approved, a final process of pre-certification through the insurance company is made, and a final surgery date and pre-operative work up are scheduled and all financial matters are settled. Pre- certification generally must take place within 90 days of predetermination to be valid.

Copay and Coinsurance

Bariatric surgery is covered by many insurance policies, and the amount that it costs depends upon the type of policy and its terms, as well as any contract arrangement with the hospital. If you wish to come to us for evaluation and surgery, we perform the insurance authorization and approval process without charge. With specific policy information and approval, we can obtain your out-of-pocket expected costs before surgery is scheduled.

University Medical Associates (UMA), the physician billing office, requires payment of your co- pay and coinsurance 14 days before surgery is performed. UMA will call and state the estimated coinsurance amount to be paid. We must, however, wait for such approval or have the financial commitment of the patient, prior to scheduling surgery.

All copayment, deductibles, and coinsurance must be paid in full prior to surgery. The financial counselor will provide you with the specific amount that is your responsibility. If you do not pay this prior to surgery – your surgery will be rescheduled.

No Insurance Coverage?

Self-Pay Option

Many patients choose to pay for the operation themselves. In cooperation with MUSC, we offer a special package for cash paying patients, which include all usual services, at a fixed fee. This fee must be paid in full prior to surgery or your surgery will be cancelled. The fixed fee is all that you will be required to pay for your hospitalization for the actual surgery – it is determined based on our expected costs. This fixed fee does not cover the costs of any pre-operative work up charges, or post-operative follow up care. If you have questions or would like a quote on the fixed fees – please call the financial counselor at 843-876-4864.

BLIS Insurance Coverage for Self Pay

MUSC Health's bariatric surgeons are BLIS surgeons.  Becoming a BLIS surgeon is a very selective process and means that we meet very high standards of short term outcomes and long term patient success.  As a result of our approval by BLIS, we are able to participate in an innovative new insurance coverage which allows us to make a commitment to our self-pay patients that, should a covered complication occur within certain time frames following surgery, our patients are not responsible for the costs associated with the care of that complication.

The complication protection is exclusively part of the package price you will pay for your weight loss surgery.  We are happy to provide this benefit to our patients and ease your mind and your wallet in this important decision to have a life-saving surgery.  Other terms and conditions apply; please contact our office and review the self-pay contract for further details about this program.

Other Options

If you would like to become an advocate for change related to bariatric surgery benefits, please visit the Obesity Action Coalition to learn how you can help to affect healthcare policy and improve access to care for the treatment of obesity.

The Weight Loss Surgery Foundation of America is a nonprofit organization that raises money to help fund bariatric surgery for those who do not have insurance coverage. Both surgeons are enrolled in the program but we are only able to refer a limited number of patients each funding cycle. Please visit the WLSFA site to learn about all the requirements.

 

Our Locations

Ashley River Tower
25 Courtenay Drive
Charleston, SC

      

Contact the MUSC Health Bariatric Surgery Program:

843-792-3046

  

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