insurance issues
Why does it take so long to get insurance approval?
After you have met with your surgeon , it usually takes your doctor's
office 1-2 days to send a letter to your insurance carrier to start the
approval process. The time it takes to get an answer can vary from
about 3-4 weeks or longer if you are not persistent in your follow-up.
Most treatment centers have insurance analysts who will follow up
regularly on approval requests. It may be helpful for you to call the
claims service of your insurance company about a week after your letter
is submitted and ask about the status of your request.
How can they deny insurance payment for a life-threatening disease?
Payment may be denied because there may be a specific exclusion in your
policy for obesity surgery or "treatment of obesity." Such an
exclusion can often be appealed when the surgical treatment is
recommended by your surgeon or referring physician as the best therapy
to relieve life-threatening obesity-related health conditions, which
usually are covered.
Insurance payment may also be denied for lack of "medical necessity." A
therapy is deemed to be medically necessary when it is needed to treat
a serious or life-threatening condition. In the case of morbid
obesity, alternative treatments - such as dieting, exercise, behavior
modification, and some medications - are considered to be available.
Medical necessity denials usually hinge on the insurance company's
request for some form of documentation, such as 1 to 5 years of
physician-supervised dieting or a psychiatric evaluation, illustrating
that you have tried unsuccessfully to lose weight by other methods.
What can I do to help the process?
Gather all the information (diet records, medical records, medical
tests) your insurance company may require. This reduces the likelihood
of a denial for failure to provide "necessary" information. Letters from
your personal physician and consultants attesting to the "medical
necessity" of treatment are particularly valuable. When several
physicians report the same findings, it may confirm a medical necessity
for surgery.
When the letter is submitted, call your carrier regularly to ask about
the status of your request. Your employer or human relations/personnel
office may also be able to help you work through unreasonable delays.
