Insurance

Payment may be denied because there may be a specific exclusion in your policy for obesity surgery or “treatment of obesity.” Such an exclusion can often be appealed when the surgical treatment is recommended by your bariatric surgeon or referring physician as the best therapy to relieve life-threatening, obesity-related health conditions, which usually are covered.

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 1 to 5 years of physician-supervised dieting or a psychiatric evaluation, illustrating that you have tried unsuccessfully to lose weight by other methods.

If you would like to appeal the decision, call your insurance company and ask what their appeal process would be. You will then need to contact your primary care physician and have them assist you in any documentation that would be needed to help with your appeal. We have not seen you in our office at this point and therefore would not be able to help in your appeal.

Once we receive the denial letter from your insurance company, we will begin to work on the appeal process. We will contact you to let you know what additional information they have requested. You may need to contact your primary care physician to request the information and have it sent to us.

Gather all the information (diet records, medical records, medical tests) your insurance company may require. This reduces the likelihood of a denial for failure to provide “necessary” information. Letters from your personal physician and consultants attesting to the “medical necessity” of treatment are particularly valuable. When several physicians report the same findings, it may confirm a medical necessity for surgery. All of this information should be sent to:

mmpc^® Weight Loss Specialists
4100 Lake Drive, Suite B01
Grand Rapids, MI 49546

You should check with your insurance company to see if your policy has a pre-existing clause. If it does, find out how long you must wait and notify us of this time frame. You will need to wait until the waiting period is done before scheduling any appointments or having your surgery. You should also let your insurance company know if you had other insurance up to the time you obtained insurance thru their company. If you had other insurance prior, the insurance companies sometimes will waive the pre-existing clause. We do not check to see if you have a pre-existing clause and you will be held liable for the surgery expenses if your claims are denied for this reason.

Currently, we do not have financing available and you will need to seek help with your financing needs from an outside source.

Blue Care Network
Blue Care Network requires documentation showing a physician supervised weight loss attempt for one (1) consecutive year within the last three (3) years. You will need to have your primary care physician send copies of your notes. The notes should include regular weigh-ins, any dietary and behavioral counseling, and any prescribed medications for weight loss. A summary letter from your physician is not acceptable. Blue Care Network requires the actual copies of the office notes. You will need to have an authorization to see the surgeon. The visits for the medical and psychological evaluations are out of pocket as the providers do not participate with Blue Care Network. Once the dictation is complete and the team feels you are a candidate for surgery, copies of the dictation and the weight loss documentation will be faxed to Blue Care Network for authorization for surgery. This process can take 30 to 45 days. Your surgery will be scheduled once authorization is received.

Blue Cross Blue Shield/Blue Cross Blue Shield PPO/Blue Choice
You should check with your individual carrier to see what their requirements are. BCBS varies on its requirements for weight loss attempts and you will need to check based on your plan and which state your BCBS is thru on the requirements. After the dictation for all of the evaluations is complete and the team feels you are a candidate for surgery, copies will be sent into your insurance for authorization for the surgery if required for your type of BCBS. Please note that BCBS/BCBS PPO of Michigan does not require preauthorization with the exception of a few employer groups. They are General Motors and Michigan Conference of Teamsters Welfare Fund. For these groups, once the dictation is completed, copies will be sent to your insurance for prior authorization. This process can take 30-45 days from the time it is sent. For employer groups that do not require prior authorization, your surgery will be scheduled as long as the entire team agrees that you are a candidate for surgery.

Blue Cross Blue Shield FEP
For BCBS/BCBS PPO Federal Employees Program, LAP-BAND® is not a covered benefit. It is listed as an exclusion on their contract.

Care Choices
Care Choices requires documented attempts at medically supervised weight loss. Please check with your insurance as to what the requirements are and if they cover the LAP-BAND procedure. You will need to have your primary care physician send this documentation to mmpc. You will need to have an authorization to see the surgeon. The visits for the medical and psychological evaluations are out of pocket as the providers do not participate with Care Choices. Once the dictation is complete and the team feels you are a good candidate for surgery, we will send the documentation to your primary care physician along with a letter to Care Choices. Your PCP will then need to send all of the information to Care Choices along with a referral request. Once an authorization is received, your surgery will be scheduled.

Commercial Carriers
You should check with your individual carrier to see what their requirements are and if they cover the LAP-BAND procedure. Appointments will be scheduled after we receive the signed fee agreement and we have authorizations for the visits if they are required. After the dictation for all of the evaluations is complete and the team feels you are a candidate for surgery, copies will be sent into your insurance for the surgery. We do require prior authorization before the surgery can be scheduled.

Managed Care Medicaid
Our physicians only participate with Priority Health Medicaid; however Priority Health Medicaid is currently not covering the LAP-BAND procedure.

Medicare
Currently Medicare is not covering the LAP-BAND procedure.

Here are three questions to ask your insurance provider for the Medical Weight Loss Program:

1. Do I have coverage for a medically supervised weight management program?
2. Do I have coverage for obesity?
3. What if my doctor recommends that I lose weight for health reasons?

The following is a list of links to insurance companies with coverage in the West Michigan area.

BCBS
BCBS of Michigan
Blue Care Network
Grand Valley Health Plan
Medicare
PPOM
Priority Health
United Healthcare

Insurance companies pay for the services that are billable to them. Before you have any appointments scheduled here, we will send to you in the mail a fee agreement. This will show you what your out of pocket expenses are. Our physicians do not participate with every insurance. For the non-participating insurances, you will be required to pay for your service at the time of service. We will courtesy bill the physician services for you and payment will go directly to you from your insurance company. There are other services that are just not covered by your insurance company. We are unable to bill for your dietitian visit, behavioral visit, exercise visit and the supplement that you are required to take prior to and after your surgery. You will receive a fee agreement at orientation showing your out of pocket expenses based on your insurance.

It takes 2 – 3 weeks from your last appointment before all of your dictation is ready to be sent in. Once it is sent in to your insurance, it can take from 1 week to 6 months before an authorization is received, depending on your insurance. Because some insurance companies require the documentation to be reviewed by their medical director, they can get backed up on reviewing the documentation. Most insurance companies have specific requirements regarding gastric bypass surgery. They will on occasion request additional information from either you or your primary care physician. You should contact your insurance company to see what their requirements are.