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Weight Loss Surgery Program

Insurance & Financing

Before you consider weight loss surgery as an option in the management of your obesity, we suggest that you contact your insurance company to verify that bariatric surgery is covered by your policy and that the MUSC Bariatric Surgery Program is part of your coverage. Some policies exclude all types of weight loss surgery, though others don't may not include a specific exclusion of surgery. Your insurance company can verify whether the benefit of weight loss surgery coverage is actually available. They may require documentation about medical necessity before making a decision. 

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.

Following is more information on these topics:

 

Medicare Information

In 2006, the Centers for Medicaid Services (CMS) approved weight loss surgery for their beneficiaries when certain criteria were met. In particular, in order to qualify for Medicare/Medicaid coverage there must be documentation in the medical record of at least six consecutive months of weight loss attempts, monitored by a doctor, during the 18 months immediately prior to the surgery. 

What does this mean for you?

  1. You will have to prove six (6) consecutive months of physician supervised weight loss attempts within the last 18 months.  Please be advised that it is irrelevant if you succeed or fail in your weight loss attempt to qualify for Medicare/Medicaid coverage.

    Proof consists of documentation of at least six (6) consecutive monthly office visits regarding your weight loss attempts by a medical doctor.  Please see detailed information below regarding office notes.
     
  2. You will also need surgical clearance by a Cardiologist and Pulmonologist (Medicaid only).
  3. You will need H. Pylori and TSH testing, which you can complete here (Medicaid only).

The following information MUST be documented in the office notes, each time you go,as office notes containing the following information is what is required:

  • Date of each office visit (at least monthly)
  • Current height and weight
  • Diet plan discussed
  • Exercise plan discussed
  • Behavior Modification
  • Progress made
  • Other Comments

Please feel free to share this information with your primary care physician. Once you gather your documentation, please turn it to the MUSC Health Bariatric Surgery Team.  You may fax it to 843-876-4201.  Be assured we will work with you to advocate for your care.

 

Insurance Benefit Guidelines

Many insurance companies have their own specific benefit guidelines, describing whether weight loss surgery 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 surgeon’s office. 

The following is a basic list of what insurance companies are requiring in order to determine if bariatric 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 REQUIRED INFORMATION:

  • Documentation of Dieting. Many insurance companies require documentation of a medically supervised weight loss attempt. This can be in the form of medical records from your primary care provider or receipts for weight loss programs. Some insurance companies have gone as far as requiring a 6-month daily record of eating habits.
  • Documenting Exercise Attempts. Many insurance companies are asking for documentation of exercise attempts. This can be in the form of attendance records at exercise programs, receipts for gym membership and records from rehab appointments.
  • Psychological evaluation. Most insurance companies require a psychological evaluation. This can be in the form of a psychological screen to test your state of mind and ability to cope with surgery and the change in lifestyle that is necessary afterward.
  • Medical records. Medical records are required, and must be submitted with all other documentation prior to the insurance company making a determination.
  • 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.
  • Predetermination. Once all your records are gathered and sent into 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 either ask for more documentation, approve this benefit for you or deny this benefit to you. If you are denied, most insurances have up to 3 appeals that they allow you to make. It is important not to waste these appeals and make sure all documentation is complete prior to filing an appeal. It is also important not to give up during the appeals process as many initial denial decisions are overturned in later appeals.
  • Pre-certification. If your benefits for treatment have been approved, a final process of pre-certification through the insurance company is made, in which the scheduling of your operation, the surgeon you will be working with and the facility at which you will undergo the procedure are determined. Pre-certification generally must take place within 90 days of predetermination to be valid.

 

Co-Pays and Co-Insurance

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 contractual arrangement with the hospital. Insurance coverage comes in many types, and coverage really cannot be predicted, since it varies from policy to policy, even when issued by the same insurance company. 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 you schedule surgery.

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

The cost of the operation includes:

  • Hospital charges – Medical University of South Carolina
  • Surgeon's fee
  • Surgical Assistant's fee
  • Anesthesiologist's fee
  • Laboratory charges
  • X-Ray charges
  • Consultant fees - as necessary
 

No Insurance Coverage or Self-Pay

Many patients choose to pay for weight loss surgery themselves. In cooperation with Medical University of South Carolina, we offer special packages for cash patients, which include all usual services, at a significant discount. The actual rate varies, depending on the type of surgery chosen, and initial weight and health status.

  • MUSC Physicians, the physician billing office requires payment 14 days before your surgery is performed. MUSC Physicians will take these credit cards: American Express, Visa, Mastercard and Discover. Payment by check will require a cashier’s check.
  • MUHA, Medical University Hospital Authority, requires payment of the estimated costs 14 days before surgery.

For self-pay patients, or patients with insurance that elect to self-pay due to lack of insurance coverage, you will be quoted a fee for your Gastric Bypass or Vertical Sleeve Gastrectomy surgery.  Please note this fee ONLY covers routine services related to your surgery and is based upon usual and customary charges.  The fee quoted for weight loss surgery includes your surgeon’s fee, the anesthesiologist’s fee, the radiologist’s fee, and the hospital charges for the surgery only.  The fee does NOT include:

  • Pre-procedure office visits
  • Post-procedure office visits
  • Diagnostic testing
  • Other professional services required as a result of a complication
  • Other services provided unrelated to your gastric bypass

In other words, if the only surgery you require is the initial planned weight loss surgery, the fee quoted is all you will owe.  If you require additional physician specialties to manage a complication, or if your surgeon finds other problems that need to be fixed, such as repair or removal of your gallbladder or a hernia, you will have additional charges from the physicians. You will be responsible for those additional professional fees.  Your hospital bill for this admission will not change, regardless of your length of stay.

Introducing BLIS Insurance Coverage

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.

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.

Non-surgical Programs at MUSC

The MUSC Weight Management Center offers a wide range of non-surgical and research programs for weight loss.

Our Locations

Ashley River Tower
25 Courtenay Drive
Charleston, SC

      

Contact the MUSC Health Bariatric Surgery Program:

843-792-3046