Obesity is a growing problem in the United States and this has fuelled the demand for bariatric surgery or weight loss surgery. Weight loss surgery helps obese and morbidly obese individuals improve their health. Most insurance companies provide coverage for medically necessary weight loss surgery, but coverage depends on several criteria and varies by state and by insurance provider. Various services and procedures also require referral and/or prior authorization. Bariatric practices need to have bariatric surgery insurance verification processes in place to confirm patient benefits prior to scheduling their appointment. Obtaining insurance verification and prior authorization can prevent claim denials and improve patient care. However, these front desk tasks are full of challenges.
Patient eligibility verification is a front-end step of revenue cycle management following patient scheduling and patient registration. According to a Claim Remedi survey, eligibility issues are one of the key reasons for claim rejections, with about 80 percent of claims submitted rejected due to eligibility issues. Insure.com reports that nearly 25 percent of patients considering bariatric surgery are denied coverage three times before their request is approved, and according to the American Society for Metabolic and Bariatric Surgery (ASMBS) this is one of the main reasons why patients who need bariatric surgery do not receive it. However, verifying coverage of bariatric surgery can be difficult. The patient’s insurance policy may or may not cover bariatric surgery and such coverage would vary widely depending on their location and employer.
The medical insurance companies that offer bariatric surgery coverage are Aetna, Blue Care Network, Blue Cross/Blue Shield, CHAMPVA, Cigna, Cofinity, Medicare/Medicaid, OptumHealth, Physicians Care Health Plans, Priority Health, Tricare and United Healthcare. Common bariatric surgery procedures are: gastric bypass, sleeve gastrectomy, adjustable gastric band, and biliopancreatic diversion with duodenal switch. While these procedures are covered by most plans, there are many procedures which insurers do not cover. Moreover, criteria vary by insurer.
When a patient schedules an appointment at a bariatric practice, the bariatric insurance verification specialist needs to verify:
- Accuracy of registration and insurance information such as the patient name, ID number, date of birth, subscriber information, primary and secondary coverage details, and more.
- If the patient’s policy has coverage for morbid obesity/bariatric – Some insurance plans clearly exclude coverage for obesity treatment, weight loss surgery, and related care, and will not cover any related charges the patient incurs from preparing for, having, or recovering from a gastric bypass procedure. The insurance verification specialist will check if the plan offers coverage for the bariatric procedure the patient needs.
- What procedures are covered – this can vary among carriers. For instance:
- Aetna covers Lap or open Gastric bypass, Lap gastric bands – Realize or Lap Band, Lap gastric sleeve and Duodenal switch
- BCBS of Texas covers Gastric bypass, Gastric banding (Lap Band and Realize Band), Sleeve gastrectomy, and Biliopancreatic bypass with Duodenal switch in patients with a BMI over 50
- United Healthcare covers Gastric bypass, Lap adjustable gastric bands (lap band surgery), Gastric sleeve procedure (laproscopic sleeve gastrectomy), Vertical banded gastroplasty, Biliopancreatic bypass, and Duodenal switch
- Medicare covers some bariatric surgical procedures, like gastric bypass surgery and laparoscopic banding surgery, when the patient meets certain conditions related to morbid obesity.
Other insurance eligibility criteria to verify coverage of bariatric surgery may include:
- Whether the beneficiary is required to have participated in a structured weight management program and for how long.
- Whether the patient meets the insurance company’s body mass index (BMI) criteria – for most, the requirement is a BMI (body mass index) of 40 or above.
- If a Bariatric Center of Excellence or COE facility is required for surgery.
- General Policy Information: annual deductible, and whether it has been met for the current year, date on which the deductible renews, office visit copay, surgery co-pay amount if any and what percentage of the surgery is covered, maximum allowable visits, and annual out of pocket maximum.
All of this information should be checked for all patients each and every time they come through the door.
Another major responsibility of the physician’s office is to obtain prior authorization. All covered bariatric surgery procedures, including revision of bariatric surgery and repeat bariatric surgery, require prior authorization. Each insurance company, including Medicare and Medicaid, has their own guidelines on prior authorization and/or referrals. The request for prior authorization must include documentation that fully supports the approval criteria, such as:
- Medical history, past and current treatments and results
- Complications encountered
- All weight control methods that have been tried and have failed
- Expected benefits of bariatric surgery in this patient
- A psychiatric evaluation of the beneficiary’s willingness/ability to alter his lifestyle following surgical intervention
All insurance companies also require a Letter of Medical Necessity for approving coverage for obesity surgery.
Delays in obtaining prior authorizations can lead to treatment delays or denials, which can affect patient care. Having a designated insurance authorization service provider deal with this task will streamline the process and ensure that authorizations are obtained before treatment.
Any changes to the beneficiary’s insurance policy may lead to a change of coverage, reimbursement, and/or exclusion of bariatric benefits. Therefore, reliable bariatric surgery insurance verification service providers always re-verify coverage as necessary. They are also familiar with the appeals processes of different insurance companies, and will help practices appeal claims that are denied.
Insurance plans have changed significantly in the recent years, leaving the patients paying more for health care than they have in the past. Verifying insurance benefits will also allow practices to understand patients’ self-pay/out-of-pocket financial responsibilities. Physicians can educate patients about their financial responsibility before services are provided so that they can prepare to pay the portion of the bill for which they are responsible. Providers can offer financing options for patients with budget constraints, which will prove beneficial for both parties.
Bariatric insurance verification and prior authorization are an essential part of the services provided by experienced medical billing companies. Their insurance verification specialists directly call up companies to verify insurance eligibility. This helps physicians submit clean claims and provides patients with the most accurate pricing information at the time of scheduling. It helps avoid the need for claim resubmission, reduces demographic or eligibility-related rejections, increases upfront collections, and improves patient satisfaction.