Information for Laparoscopic Gastric Band Patients
We at Florida Obesity Surgical Associates (FOSA) are committed to providing our patients with the best possible care, but we also recognize that it may be difficult for many of our patients to afford the costs associated with LAP-BAND® or Realize Band® surgery. If you decide to pay for the procedure yourself, we will assist you in exploring various financing options that can help you manage the costs. Alternatively, for those patients seeking insurance coverage we will make every effort to work with you and your insurance company to maximize your benefits under your existing insurance plan.
To start the process, everyone must first attend our FREE informational seminar or make arrangements through our office to participate in our FREE online seminar! If you have not already done so, please call the number listed below to reserve your place at a scheduled seminar. The date, time, and location of the seminars are listed on our website at FloridaObesitySurgical.com as well as other useful information.
In order to successfully navigate the healthcare system, there needs to be careful planning and preparation on your part both before and after surgery. Understanding the steps and potential issues in the self-pay or insurance coverage process will help ensure you the best possible outcome.
Self-Pay Patients
The advantage of the self-pay option is it greatly reduces your wait time to schedule surgery. In addition to reducing your wait time before surgery, there are significant tax advantages to paying for the surgery yourself. Bariatric surgery, when paid for directly by patients, may be tax deductible as it is considered a "major medical expense." Please consult your tax advisor on how you may be able to benefit from this helpful tax deduction.
Other Options for Self-Pay Patients
Patient financing programs, such as Care Credit and SurgeryLoans.com focus exclusively on patient financing for elective procedures including bariatric surgical procedures. Their informational websites can be found at Carecredit.com and SurgeryLoans.com. Home equity loans or other special financing through a local bank are other options you may consider.
Steps in the Insurance Coverage Process
Please review the following steps carefully, and feel free to contact our insurance specialist with any insurance-related questions you may have. 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 navigate successfully through the insurance coverage process.
Step 1: Call the customer or member services phone number listed on your insurance card.
We have prepared a worksheet to help you document your insurance benefits for morbid obesity:
Your Insurance Company Criteria for Bariatric Surgery
YES/NO
1. Is surgical treatment for morbid obesity a covered benefit?
2. Is CPT Code 43770 (laparoscopic adjustable gastric banding) a covered benefit?
3. Does the consultation with a bariatric surgeon require a primary care physician's referral? (If yes, contact your primary doctor to secure a referral.)
4. BMI over ___________________________________________________________________________
5. Within the last ________ years you must have ________ months of medically supervised weight loss
program with at least ________ consecutive months.
Step 2: Collect your medical records if required by your insurance company.
Most insurance companies require that you have tried to lose weight through a physician-supervised weight loss program before they authorize the gastric band surgery. Sometimes this can be accomplished through your primary care provider. Secure a copy of your medical records from your primary care provider and any specialist who has treated you and has weighed you. You will need to submit these records to our office so that we can submit them to your insurance company during the pre-determination process.
Step 3: Schedule an appointment with the psychologist.
A psychological evaluation is an integral part of the journey towards bariatric surgery, and is a prerequisite to gastric band surgery. Please speak with our bariatric coordinator for a list of approved psychologists.
Step 4: Schedule a consultation with our LAP-BAND®/Realize Band® surgeon.
After you see our surgeon, he will prepare a letter of medical necessity for us to submit to your insurance company along with all of your medical records to substantiate medical necessity.
INSURANCE PRE-DETERMINATION PROCESS
After your initial consultation, we will submit to your insurance company the application packet to request the pre-determination authorization for coverage for the gastric band surgery.
· Generally, your insurance company will take 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" phone 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. With each call, be sure to document the number you called and the name of the person you spoke with; the date and time.
· Once you have received an approval letter from your insurance company, we can proceed with preparing you for the gastric band surgery.
· If benefits are denied, you have the option to appeal your insurance company's decision. We will help you as much as possible with this process.
NOT COVERED?
Be persistent! If your insurance company tells you that the surgery is not covered, you should obtain the printed exclusion section of your insurance policy. Read it carefully. You may want to visit www.obesitylaw.com. There is some information on this website regarding the exclusion language that may be helpful. Depending on how the exclusion is written, you may be able to overturn the insurance company's decision.
THE APPEAL PROCESS
In the event that your request for insurance coverage of bariatric surgery is denied, you have the option to.
appeal the denial of coverage.
· Appeals should be initiated by the patient. We will help you access the LAP-BAND® or Realize Band® System Hotline to assist in this process.
· Typically, insurance companies require that a patient appeals the decision within 30-60 days after receiving a denial of coverage letter.
