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Insurance and Paying for Gastric Bypass Surgery

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Updated February 15, 2014

Doctor

Your doctor is an important part of the approval process.

Photo: © Jupiterimages Corporation

Paying for gastric bypass surgery is a top concern for those who are candidates for the procedure. Having medical insurance doesn't mean you won't need to pay for all or part of the procedure yourself. This article will help you learn more about insurance and paying for gastric bypass surgery.

 

Gastric Bypass and Health Insurance

According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), gastric bypass surgery costs between $20,000 to $25,000 on average. Whether or not the procedure and related costs are covered by health insurance depends on your insurance company, your state, and your specific policy, among other factors.

It is important that you review your policy or speak with your insurance company directly to determine if you are covered. Some insurance plans explicitly exclude obesity treatment, weight loss surgery and related care, which means that they will not cover any related charges you may incur from preparing for, having, or recovering from your gastric bypass procedure.

 

The Pre-authorization Process

If you are covered by an HMO, you will need to see your primary care physician to obtain his approval before seeing a specialist like a bariatric surgeon (a specialist who performs weight loss surgery). Once you have seen the specialist and have been deemed a candidate for weight loss surgery, you will need to begin the pre-authorization process.

The approval process for weight loss surgery can be a bit more complicated than it is for other common medical procedures. It is likely that your insurance company will request both your physician and your surgeon send in something called a "letter of medical necessity" as part of the weight loss surgery pre-authorization process. Basically, your doctors will relate to the insurance company how having the procedure will improve your health and overall well-being.

At this point, your request for authorization will be approved, denied, or the insurance company will request additional information. Your doctors may need to follow up with phone calls, further documentation, or additional letters as requested by your insurance company.

If you are denied pre-authorization by your insurance company, you can appeal the decision. All insurance plans offer an appeals process and they are legally obligated to disclose to you your right to appeal. You are typically allowed a 30 to 60 day window from the date you were denied to appeal. The process usually begins with a letter of appeal being sent in to the insurance company by you, your surgeon and your primary care provider.

A Caveat

Those whose surgery is pre-approved and covered by insurance should remember to factor in any co-pays or co-insurance costs that will need to be paid out-of-pocket. These costs should be clearly specified by your health insurance policy.

 

Medicare Coverage May be Available

If you are on Medicare, a portion of the costs of gastric bypass surgery and related care may be covered, but only if you are both obese and suffer from an obesity-related disease such as type 2 diabetes or coronary heart disease. For the expenses to be covered, you must have the procedure at a Medicare-approved facility.

Medicare does not cover weight loss surgery for patients who are overweight but do not have any of the specified related health problems, even if a doctor has officially diagnosed the patient as being obese. Contact your regional Medicare office to learn more.

 

Self-Pay Patients

If you do not have health insurance, or, your insurance does not cover weight loss surgery, you will need to cover your costs yourself. This is referred to as being a self-pay patient. Hospitals offer payment plans for some services allowing you to make payments towards some or all of your expenses rather than being charged in one lump sum. Another option is to pursue private financing from a lender for your medical expenses, but as with any other type of personal loan, you will need to consider the finance charges (interest rate) and fees.

 

Adding Up the Costs

If you decide to obtain financing for medical costs from a private lender, you will need to factor in all of the expenses you will be faced with when calculating the amount of financing you need. Your physician should able to provide you with details about the anticipated costs.

Typical expenses include:

Whether you choose private financing, or a payment plan with the hospital, you will need to establish exactly what your payments will be, and if they're due bi-weekly or monthly, so you can plan your budget accordingly.

 

Learn More

About.com's Guide to surgery has provided an excellent article on ways to pay for surgery including using your retirement savings and obtaining loans.

 

Sources:

HHS/Centers for Medicare and Medicaid Services. Medicare Expands National Coverage for Bariatric Surgery Procedures, 21 February 2006. Retrieved 16 June 2008.

Manfred, Erica. The Doctor's Guide to Weight Loss Surgery. West Hurley, NY: Fredonia Communications, 2001.

National Institute of Diabetes and Digestive and Kidney Diseases. Bariatric Surgery For Severe Obesity. Retrieved 16 June 2008.

 

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