Logo for: PRIA Appeals

ASMBS Presentation Wrap-Up: Access to Care & Insurance Obstacles Faced by Patients & Providers

On July 2, 2021, PRIA Appeals’ Walter Lindstrom addressed an international audience of physicians training to become Fellows of the American Society for Metabolic & Bariatric Surgery (FASMBS) on the topic of Access to Care and Health Insurance Obstacles.

Since 1998, Walter has been a Member of the ASMBS Integrated Health section and frequently lectures about bariatric surgery insurance coverage, reimbursement and patient appeals. His presentation to this group was a high-level overview of some of the challenges faced by their patients and how they can help in their new roles as Fellowship-trained bariatric/metabolic surgeons. 

Insurance and patient access challenges vary greatly depending on where a physician practices. Because Fellows often take positions in a different state than where they trained, an important takeaway message of the presentation was: “All insurance is local, and you need to understand the issues in your area of practice.

Walter reviewed some of the challenges providers and patients may experience:

  • Contract exclusions for diseases and procedures
    • SADI-S and other E/I procedures
  • Unreasonably restrictive medical policies
    • Mandatory supervised weight loss programs 
    • Adolescent ​criteria and age limits
    • Diabetes Surgery
  • Mandatory supervised weight loss programs
  • Revisions and conversions
    • RNY for GERD

Challenging insurance denials for weight loss surgery can sometimes be successful when a bariatric surgeon can convince an insurer’s Medical Director during a “peer-to-peer” conference. However, patients possess more robust appeal rights, including one or two internal appeals through their insurer.

Should the payer not overturn its original denial after its appeal process is exhausted, patients can take the next step: an external, independent review process, where an unbiased expert bariatric surgeon—who has no connection to the insurance company—will decide whether the denial should be overturned.

The importance of encouraging patients to request an independent review and not give up was stressed to the Fellows. Walter emphasized: “Independent reviewers are not bound by an insurer’s medical policy, so this process is often the best chance a patient has to get the full and fair review they are entitled to receive.”  

PRIA Appeals is always ready to help a physician or bariatric surgery program learn the best way to submit authorization requests and, if needed, work to ensure that their patients can get the expert help they need to navigate this complex process.

Refer a Patient to PRIA Appeals

If you have a patient who has been denied insurance coverage for a necessary medical surgery, procedure or treatment, PRIA Appeals can help. Please call us directly at 877.992.7732 or submit a contact form to refer your patient to PRIA Appeals and let us help them get the care they need.