Insurance Issues

Our Frequently Asked Questions section references accepted standard of practice and guidelines from regulatory and professional organizations including the National Institutes of Health (NIH), American College of Surgery (ACS), American Society for Metabolic and Bariatric Surgery (ASMBS) As always, please check with your healthcare provider to determine their individual practices, guidelines and what they recommend for you.

Why does it take so long to get insurance approval?
Simply put, to get insurance approval you must have weight loss surgery as a covered benefit in your plan and then meet the criteria your plan requires. This is called verifying benefits and you as a member or beneficiary of the insurance plan can verify your benefits. Call the customer service number on your card and ask the insurance representative to check your plan for coverage of weight loss surgery. Our office staff will also be verifying the weight loss surgery benefit.

Once verification has been completed then you must document meeting the requirements set forth by your plan and formally request the insurance company to authorize payment for the surgery. Our office staff will assist you in understanding, documenting and submitting for authorization. When we have submitted all the required health information to your insurance company it can take up to 4 weeks to receive notification of approval or denial. Most insurance companies state that notification will be provided within 14 business days. Our office staff regularly monitors the progress of your request. It may also be helpful for you to call the claims service of your insurance company about a week after your letter has been submitted and ask about the status of your request.

How can they deny insurance payment for a life-threatening disease?
Authorization for surgery may be denied for reasons that are specific to the health insurance plan being provided by your employer. Most commonly they are the weight loss surgery benefit does not exist; has been excluded from your policy or the documentation submitted for authorization does not meet the criteria required as medically necessary; such as 3 to 6 months of physician-supervised dieting or 5 year history of morbid obesity as documented by a primary care provider with a date range.

Insurance payment may also 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 participation in a 6 month to 1 year physician-supervised dieting program and/or a psychiatric evaluation, illustrating that you have tried unsuccessfully to lose weight by other methods.

What can I do to help the documentation of meeting insurance criteria?
Gather all the information (diet records, medical records, medical tests) you may have from previous attempts at loosing weight. Ask questions if you don't understand and be patient. Our staff are proficient in interpreting what is needed and acceptable documentation and we will assist you. We will not knowingly submit for authorization if we feel your request is lacking in the documentation.

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Howard University Hospital • 202-865-1286 • 2041 Georgia Ave. NW, Washington, DC 20060
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