Insurance Issues
Why does it take so long to get insurance approval?
After your surgical consultation is completed, it usually takes your doctor a day or two 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 three to four weeks or longer. 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?
Payment may be denied because there may be a specific exclusion in your policy for obesity surgery or "treatment of obesity." Such an exclusion often can 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 also may 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 one to five 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 also may be able to help you work through unreasonable delays.
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