insurance

The following steps may seem difficult and confusing, but please know that help is available. If you choose to register with Dr. Thomas for surgery, a process is in place that will help you through the unfamiliar insurance process.

1. Benefit Verification. Do you know if surgical treatment for morbid obesity is a covered benefit under your specific policy? Review your benefits brochure and look for any exclusions of this benefit. If no exclusion exists, a representative of the insurance company is contacted to verify whether the benefit is actually available. Your insurance may give a yes or no answer, or they may withhold information until all documentation has been received and a pre-determination has been made about the necessity for you to have surgery.

   Please note: "Obesity" and "morbid obesity" are defined as different health conditions. Some insurance plans will reject treatment for obesity but will cover treatment for morbid obesity. Be precise in the words you use when working with insurance companies.

   Check more than one source when verifying your insurance policy benefits for morbid obesity. Unfortunately, not all representatives are knowledgeable about their policies and may not know what morbid obesity is. This lack of knowledge could result in you receiving wrong information.
   

2. Medical records. Medical records must be submitted with all other documentation prior to the insurance company making a determination.
3. Documentation of Dieting and Exercise. Insurance companies often require your diet/exercise records you may have from participation in commercial weight loss programs, gym memberships, rehab appointments, medical records your primary care provider may have, or any weight loss program receipts you may have kept. Some insurance companies are now asking for a six month daily record of eating habits and physician monitored exercise program.
4. Psychological evaluation. To ensure that you are mentally stable to withstand surgery, insurances normal requires a psychological evaluation. Through our website, a free online psychological screening test is used to aid you if this is a requirement.
5. Letter from your bariatric surgeon. Your surgeon writes this letter summarizing your medical, diet, and exercise history and your present health status. The letter helps outline why surgical treatment for morbid obesity is medically necessary. This letter is submitted with all your other medical history and documentation and a pre-determination is requested that the insurance company will pay for the surgery.
6. Predetermination. Once all of the above is sent to the insurance company, they begin a review process of your information to determine if they will approve this benefit for you. They may ask for more documentation from you, or approve or deny this benefit from you. If you are denied, you can appeal the decision. Most insurance companies have three appeals that they allow you to make. Make sure all documentation is complete prior to filing an appeal. Some initial denial decisions are overturned in later appeals.
7. Precertification. After your benefits for surgery are approved, the insurance company has a final step called precertification. This occurs after they receive the following information: 1) when your surgery is scheduled; 2) what surgical procedure you have chosen; 3) what surgeon you have chosen; and 4) what facility you have chosen. Precertification generally must take place within 90 days of predetermination to be valid.