While the Lap-Band System
procedure is increasingly covered by insurance policies due to a
growing recognition by the healthcare industry of the high costs
associated with obesity and obesity-related health problems, navigating
the insurance process can sometimes be overwhelming. That
is why at DayOne we have dedicated insurance specialists on staff
to help you manage the insurance approval process and understand all of
your available options. If you are seeking insurance coverage, we will
make every effort to work with you to maximize your benefits under
your existing insurance plan. In the interim, we have
developed a list of the steps (below) involved to help get
you started on understanding the Lap-Band insurance approval
process. The more you learn about the process in advance and
the more information you can provide up front, the faster your request
will be processed and the greater the chance you will have a
successful end result. Once you have reviewed the following,
if you have any additional questions about coverage, please
contact our Insurance Coordinator:
Insurance Coverage Process
Based
on your insurance coverage, please review the following steps
carefully. While it may seem overwhelming at first, as long as you
follow each step, keep yourself informed on the issues and document everything, you will be able to successfully navigate the insurance coverage process.
STEP 1: Call your Insurance Company
Note: Before you begin, it is important for you to know your height, weight, BMI, diet history and any obesity related medical problems you may have. Have all this information ready wheyn you call.The
first step in obtaining insurance coverage for your Lap-Band procedure
is to contact your insurance company directly to find out. Call the
Customer or Member Services line listed on your insurance card and ask
the following question: - Is weight loss/obesity surgery (or "bariatric surgery") a covered benefit?
If the answer is "yes", then ask:
- Is the Lap-Band (or "Adjustable Gastric Banding") procedure approved?
(CPT Code #43770)
and
- Can you select whatever surgeon you want?
Important: You may also want to request a copy of their policy on the surgical treatment of morbid obesity. Be sure to write down: 1) the date you called, 2) the name of the person you spoke with, and 3) their extension.
Not covered? - Be persistent!
If
your insurance company tells you that obesity surgery or the
Lap-Band procedure is not covered, you may need an attorney to help you
prove the medical necessity of the procedure. Another great resource is www.obesitylaw.com.
The founder of the site, Walter Lindstrom, is a bariatric surgery
patient dedicated to providing insurance advice for obese patients. His
website offers a very helpful article entitled, " So you want to get your insurance company to cover surgery?" which we highly recommend. Covered? - Proceed to STEP 2
If you find out the procedure is covered, proceed to STEP 2, following the steps according to your insurance coverage type:
- PPO Coverage - STEP 2 (a)
- HMO Coverage - STEP 2 (b)
STEP 2(a): PPO Coverage
- Receive a "Physician Evaluation" by our surgeon during your initial Lap-Band consultation appointment at DayOne.
- The Physician Evaluation is then sent by DayOne to your insurance provider along with a "Request for Pre-Authorization" for coverage.
- Generally, your insurance company will take anywhere from 4 to 6 weeks to respond to this request.
- While
you are waiting for a response, we recommend that you follow-up
directly with your insurance company by calling the Member Services
number on your insurance card. When you call, indicate that you are
checking on the status of your "Pre-Determination Request." They will need your member ID number listed on your card to access the information on the status of your request. Be sure to document the number you call and who you spoke with during each call.
- Once you have received an "Approval Letter" from your insurance company, you can proceed with scheduling your Lap-Band surgery.
If benefits are denied, you have the option to appeal your insurance company's decision. See "STEP 3: The Appeal Process" below for more information.
STEP 2(b): HMO Coverage
- Obtain a Referral from your Primary Care Physician ("PCP") before making a Lap-Band consultation appointment at DayOne.
- Receive a "Physician Evaluation" by our surgeon during your initial consultation visit.
- The Physician Evaluation and a "Referral Request" for pre-operative testing and surgery will be submitted to your primary care physician ("PCP") or medical group.
- We
recommend that you follow-up on the Referral Request by contacting your
PCP or medical group indicated on your insurance card and asking about
the status of the request. Be sure to document the number you call and who you spoke with during each call.
- If you receive a "Referral for Surgery", you can proceed with scheduling your Lap-Band surgery.
If benefits are denied, however, you have the option to appeal the decision. See "STEP 3: The Appeal Process" below for more information.
STEP 3: Appeal Process
In
the event that your request for insurance coverage of the Lap-Band
surgery is denied, you have the option to appeal the denial of
coverage:
- Appeals can be processed either by DayOne or by the individual patient.
- Typically, insurance companies require that patients appeal within 30-60 days after receiving a denial of coverage notice.
- The appeal should include information that disputes the insurance company's reasoning for denial of coverage (for example: medical journal articles, copy of patient's insurance policy, etc.).
The
following websites are dedicated to helping patients with insurance
authorization issues and are terrific resources for patients with
insurance concerns:
Please feel free to contact DayOne with any questions or concerns you may have - we are here to help! |