Do you think they are here for your health?
There is an increasing incidence of obesity in the United States and an increasing interest in weight loss surgery. Because of this, insurance companies are trying a variety of methods to limit the number of people who have the operation. Now, you are probably wondering why they would do this when the long-term benefit of the operation is so clear—decreasing requirements for various medicines, fewer long-term health problems, and so forth.
Insurance companies are bottom line corporations. They care about what is going to happen this fiscal year, not what will happen in ten or twenty years.
Some insurance companies are that short sighted. Imagine that you are an executive with an insurance company. Last year your company had to pay for a thousand weight loss surgeries. It is now March and you have already approved your first thousand payments. How do you decrease your payout?
Insurance companies use tricks to deny weight loss surgery claims
First they require you to undergo several months, or sometimes up to a year, of a physician-supervised diet plan, so this puts off the weight loss surgery for a year. Of course, you don’t improve, as there is no known diet plan that works well for morbidly obese people. So what do you do? Contact your family doctor and begin a physician-supervised weight loss program right away. Tell him or her that you want to come in to discuss your weight, meet with a nutritionist, and that you want to weigh in weekly. When you come in for weekly weigh-ins, you do not have to meet with the doctor. Tell your doctor that you need each weigh-in documented in your chart so that he/she can prepare a letter to the insurance company and outline your progress, or lack of it, and the need for weight loss surgery.
Some weight loss doctors may prescribe prescription medicines…
…and some may not—that is optional. Some of those medicines can have side effects, so before you take any medication for weight loss make certain you understand the side effects. Your physician may do some blood tests on you, check your cholesterol, blood sugar and a few other items before you begin. Having a physician-supervised program shows the insurance company that you are interested in your health and that you have tried to lose weight. The weight loss surgeon should not run this program and insurance companies will not accept such programs, so ask your primary care physician to start this process.
A limited number of bariatric surgeons means you wait a long time
Another way insurance companies cut costs is by limiting the number of surgeons who specialize in weight loss surgery. In Phoenix, Arizona a lot of insurance company clients belong to health maintenance organizations (HMOs). Some HMOs now have only one or two bariatric surgeons do all of their work. Typically, this means that there may be only one weight loss surgeon in your area or HMO approved to do bariatric surgery. That weight loss surgeon may be quite overwhelmed and you might end up on a very long waiting list.
New Jersey leads the way in Lap-band surgery health insurance
A New Jersey state law states that if the insurance policy covers the weight loss surgery and if the hospital is in the network, then the insurance company is obligated to pay the hospital bill (but not the weight loss surgeon) and the policyholder can choose the bariatric surgeon for the procedure. This means that you have to pay the surgeon directly for the weight loss surgery, which amounts to a little over $3,000. However, it is one way in which New Jersey patients have a choice of weight loss surgeons that other states do not.
Some insurance companies exclude weight loss surgery from the benefits
This is a devastating approach. Some of these exclusions are written very specifically and some are not. It is important to check the language of them carefully. For example, some insurance policies do not cover obesity, which is different from the definition of morbid obesity.
Remember that sometimes the best operation for a co-morbidity of obesity is bariatric surgery. For example, while the insurance company might not cover surgery for weight loss, they might consider it for people who need joint replacement, but the orthopedic surgeon will not replace the joint unless there is weight loss—so the operation is actually for joint problems. Another is sleep apnea, which can be cured by weight loss. Therefore, while they might not cover surgery for weight loss, they might for the co-morbidity of obesity.
View policy exclusion carefully and if necessary, have them reviewed by a lawyer who specializes in this field—such as Walter Lindstrom at http://www.obesitylaw.com. If you don’t understand the exclusion, if the exclusion is buried somewhere in the insurance policy or, if it is in small print, then you might be able to get this provision overturned. Mr. Lindstrom states that he has had success in overturning fifty percent of these “exclusions.” So, do not give up—do research and get professional help.
Famous Bad Health Insurance Company Decisions
Insurance companies have not yet realized how the World Wide Web has organized obese patients. One local insurance company made it easy for patients to obtain weight loss surgery and in the course of a year, many new policyholders switched to their company. They were shocked at how many came to their company simply to have their bariatric surgery covered. They quickly began to find ways to reduce the number of weight loss surgeries they would have to pay for. Here are some of the more egregious attempts by insurance companies to keep you from having weight loss surgery.
- increased the requirement to a BMI of 50
- required you to sign up for year-long weight loss plan supervised by a physician
- gave exclusive contracts to one or two weight loss surgeons to limit access
- determined some weight loss surgeries are “experimental” or “investigational”
- approved weight loss surgery but made the patient responsible for the price of the Lap-band ($3,000)
- contracted with bariatric surgeons to pay less per case if they do weight loss surgery on more than five policy holders per month
Some insurance companies are interested in their bariatric surgery patients’ best interest
…truly interested (pending appeal)
Recently I had a patient who decided the duodenal switch surgery was appropriate for him even though his insurance company had a policy exclusion for DS. While appealing the case, he compiled a huge body of information about the DS and put it together in a binder. One of the medical directors of the company called me and said he was taking a leave of absence just to study the information so that he could bring a recommendation back to the medical policy board. That is a good insurance company (name withheld pending appeal).
There are many levels in insurance companies and some care about the health of their policyholders. However, insurance is a business, and with the rise of obesity and weight loss surgery, there will be more hoops to jump through as time goes on.
Why Not Pay Cash for Gastric Sleeve or Lap-band surgery?
Some people wish to save up their money and pay for their hospitalization and fees with cash. There is one problem with paying for weight loss surgery. Unless you live in New Jersey, you may not be eligible for any further care related to the bariatric surgery without paying additional fees. Still, if saving up money and paying cash is the only option you have, this can be the best investment you ever make.