Imagine this scenario: Your body mass index is well above 40, you have several obesity-related diseases and you’ve tried and failed numerous diets over many years. You are finally ready to consider weight loss surgery. You are medically qualified for bariatric surgery and you are committed to making the changes necessary for the procedure to succeed. Your primary care doctor is very supportive.
You go to a patient seminar at a respected bariatric center and get very excited about your surgical options to improve your health. At the seminar you sign a couple of forms, they copy your insurance card and you get a phone call that your insurance covers surgery.
You invest several hundred, maybe even over a thousand dollars going through the process your program requires:
- You pay for and complete a six-month diet (even though it’s not supported by evidence-based medicine)
- You pay for a sleep study because it wasn’t covered by insurance
- You pay a substantial share of the psychological evaluation because the provider was out of network
- You pay your co-payment for the nutritional evaluation performed by a dietician
- You pay out of pocket for a physical therapy evaluation
You get the exciting news that you passed the program and they are ready to submit to insurance.
Now, imagine getting a call from the bariatric program’s “patient advocate” telling you they won’t submit a request for authorization to your insurance company because you don’t meet the insurance plan criteria and you would be denied.
“They require you to have a BMI over 40 for the last 5 years and your BMI was 38.4 in 2009 according to your chart. You wouldn’t be approved,” she says.
“But that was when my doctor put me on Phentermine,” you reply, “I lost weight but my blood pressure shot up so he took me off it and I gained the weight right back!”
“I’m sorry but that’s what your insurance company says,” she responds. “There’s nothing I can do.”
All the money and time you’ve spent getting ready, all the plans you’ve made for your surgery and recovery time, all your hopes, gone.
We work with many compassionate bariatric providers who truly do everything they can to help their patients get insurance coverage for the treatment that is right for them, and many of them won’t believe this type of thing really happens. Sadly, it happens more than it should.
We are in the business of appealing insurance denials, but in this case no appeal was possible because the case never even got to the insurance company, it was rejected by the very people who are supposed to be the patient’s best advocate—their provider. By refusing to submit an authorization, the doctor’s office takes away any recourse the patient has to fight the denial, because the insurance company never denied it, the provider took that decision out of their hands.
Why would a bariatric provider do this? All they have to do is submit the information and get the payer’s answer. Even if the answer is No, the patient can appeal, and the provider stands to benefit greatly if that denial is overturned.
I believe that doctors and healthcare professionals should be calling the shots regarding what is or is not “medically necessary” for their patients.
We hear from many sources across the country that the number of bariatric surgery cases is declining. Providers tell us they are performing fewer surgeries. Industry representatives confirm their accounts aren’t as busy. There is a simple solution: if you have a patient who is a good candidate for bariatric surgery and wants to have the procedure, help them get it! They need someone who will advocate for them and get them access to the care they need, not make preemptive decisions based on what the insurance industry says.