Financial & Insurance Information

Please do not let cost stand in the way of improving your health. Weight Loss Surgery may or may not be covered by your insurance company. Some insurers and certain plans will pay for Gastric Bypass and some pay for the LapBand. The financing of these two different procedures has some common features, but is very different, so read each section carefully for more information.

Lap-Band Weighing Your Options

Pre-operative consultation and pre-operative work-up.
There will be costs associated with pre-operative consultation and the pre-operative work-up necessary to determine that you are an appropriate candidate for Weight Loss Surgery. Depending on your health and your surgeon’s concerns there may be tests and consultations done to assess the exact state of your health, and in order make your surgery safer. Your insurance company may not cover this. You may want to discuss this up front with your insurance carrier and/or with your surgeon at the start of your consultation.

Psychological Evaluation.
It is necessary for you to undergo a psychological evaluation before your surgery. Some insurance companies require it, however we insist on this to determine that you are not only an appropriate candidate for surgery, but it is the right time in your life to undergo the dramatic life change that weight loss surgery will provide. Weight loss surgery candidates are NOT crazy, and they have been shown to have no more psychological pathology than normal weighted people. We feel this evaluation contributes significantly to the safety of your surgery and postoperative life. Your insurance company may not cover this psychological evaluation. Please discuss coverage with our program specific psychologist. We do value the input of your own psychiatrist, psychologist, or counselor, but our psychologist has significant training and experience specifically in the evaluation of patients for weight loss surgery. Our psychologist understands the surgery; it’s postoperative demands and shares the surgeon’s philosophy of evaluation and care.

Dietary Counseling.
You will meet with our program specific registered dietitian and will receive an extensive manual on how to use your “anatomical weight loss tool.” Your need to intimately understand the lifestyle changes necessary to be successful after weight loss surgery before you make your final decision for surgery. Your insurance company may not cover this dietary counseling. Please discuss coverage with the dietitian at the time of the consultation. Our program specific dietitian has significant training and experience specifically in the education of patients prior to weight loss surgery. Our dietitian understands the surgery; it’s postoperative demands and shares the surgeon’s philosophy of evaluation and care.

The Cost of the Operation.
The cost of the operation itself generally includes, but may not be limited to:

• Hospital or Surgery Center charges
• Surgeon's fee
• Surgical Assistant's fee
• Anesthesiologist's fee
• Laboratory charges
• X-Ray charges
• Consultant fees (such as radiology interpretation) - as necessary

Weight Loss Surgery is often covered by insurance policies, and the amount that it costs depends upon the type of policy and its terms.

Costs after your surgery. The costs of your surgery are for the surgery alone.

LapBand. With the Lap-band package price, you get six months free follow up with band adjustments. You will be financially responsible for follow up visits after that one year. Some insurance companies will cover the visits and fills after six months but probably will NOT with the present state of affairs.

Gastric Bypass. Follow up of an uncomplicated postoperative course is free for ninety days. You will be financially responsible for follow up visits and testing after that ninety day period, however many insurance companies cover the visits and the necessary laboratory tests. We have a very formal follow-up program with this operation at 10 day, 1 month, 3 months, 6 months, 9 months, 1 year, 18 months, and every year after that around the anniversary of your surgery. We highly recommend lifelong follow-up by your surgeon. We also have a substantial lab testing regimen that you may be financially responsible for. For the most part, some insurance companies pay for this follow up and some will not. Vitamin therapy is absolutely mandatory after Gastric Bypass, and you will be responsible for purchasing (and taking) daily vitamins. Insurance carriers generally will NOT cover vitamin therapy and they can be quite expensive. Please educate yourself before your surgery and ask questions to get more complete information. We cannot guarantee that you will not have out of pocket expenses associated with proper follow-up of this life changing surgery.

The Cost of Complications.
Whether you have the LapBand or the Gastric Bypass, you may be financially responsible for complications. We try to minimize the chance of complications and the patient has a major role in helping to avoid complications. Nevertheless, if you have or are even suspected of having a complication it may necessitate some very expensive testing, hospital admission, or even surgery. We cannot guarantee that your insurance company will cover these costs, although some might. The coverage for LapBand may differ from the Gastric Bypass patients.

Cash pay patients and Complications: Please think very carefully about and speak to your insurance carrier and your surgeon if you plan to pay cash for your operation in regards to what may happen if complications occur. You may be and probably will be financially responsible.

The differences in Insurance Plans.
Insurance companies are very different, and each insurance company has a number of plans. Your written policy may have a number of different phrases that can be interpreted in various ways by the administrators of the plans, such as “obesity” versus “morbid obesity”, “medically necessary”, “experimental” etc. Many insurers recognize the long-term benefits of our program, and their approval process can be routine. Others are just becoming aware and can it can be very difficult and laborious to get verification of benefits. It is a good idea to read your policy very carefully and to speak with their representatives if necessary. Our insurance experts at CRMC Lifestyles Management may be able to help you sort through this. We have specific information and criteria for a number of local insurance plans and we might be able to give you some specifics based on our experience with these plans.

Criteria.
If your plan covers weight loss surgery, a number of them generally follow the criteria set forth by the National Institutes of Health, but the details vary widely.

Weight Criteria.
Many insurance companies will follow criteria listed above, and others use criteria such as insisting that you are more than 100 lbs over your ideal body weight, and/or are more than two times your ideal body weight. (See our “Do I Qualify Surgery” part of our Website). If you meet these weight criteria, some insurance companies will want certain parts of your workup done before we apply for benefits, such as the psychological evaluation, the dietary consultation, or certain lab values.

A Trial of Medically Supervised Weight Loss.
Your insurance carrier may insist on number 2. in the NIH criteria above, even though there literally is no evidence in the medical literature that patients that are severely overweight can successfully lose weight and keep it of for an extended period of time. The insurance company may ask for specific documentation of a physician-supervised diet. If that is your case, we offer a comprehensive and appropriate MEDICAL weight loss program to help you qualify for weight loss surgery benefits. Other carriers simply want good evidence that you have sincerely tried other non-surgical weight loss techniques before they give benefits for a surgical solution. We believe that insurance companies insist on a robustly documented weight loss history to demonstrate that the patient can be compliant with the life changes necessary after weight loss surgery.

For these reasons, WE CANNOT EMPHASIZE ENOUGH how important it is that the patient fills out the pre-consultation paperwork in as much detail as can be remembered. A good and well-documented dietary history can make the difference in getting benefits and not getting benefits. Please also realize how important it is to document MEDICAL PROVIDER supervised diets because of the NIH 2.criterion above: "Patients should have  a trial of medically supervised weight loss."

Please take your time and think carefully making sure for each weight loss attempt you record:
  1) Whether it was supervised by a medical practitioner.
  2) If you had involvement of a dietitian.
  3) If you were on any weight loss medications (and if they were prescribed by a medical practitioner?
  4) If you have a psychologist or behavior counselor involved in your weight loss attempts
  5) You had any exercise counseling.
  6) What sort of exercise you were involved with at that time.
  7) How long the attempt at weight loss lasted.
  8) How many pounds you lost.
  9) How many pounds you regained.

A good and well-documented dietary history can make the difference in getting benefits and not getting benefits.

Insurance Request: The Letter Of Medical Necessity
Once you have provided your surgeon and the program a completely filled out set of preoperative forms (accept our apologies for their great length) and the appropriate supporting documentation, you will have a consultation with the surgeon. It is helpful to get benefits for surgery to have a letter of support from your primary care physician as well as specialists and mental health providers who care for you. The EMC Lifestyles Management personnel and your surgeon will prepare a Letter of Necessity to your insurer, written with their specific criteria for weight loss surgery.

Please take note that it takes a highly variable amount of time for all the information to be gathered and to have the letter of necessity prepared. We may have to wait for certain documentation to send it. This process can take many weeks, so please be patient. After your insurance company receives your letter, they may send a confirmation of benefits to us expediently or may take a variable amount of time. This also may take may weeks.
Once you have verification of benefits for weight loss surgery from your insurance carrier, we can then generally schedule a surgery date. Availability of operating room opportunity can vary, and once again you may have to be patient. Overall, it may take many months between your personal decision for weight loss surgery and your actual surgery.

Your pathway to surgery:
1. Attend a free informational lecture
2. Fill out dietary and medical questionnaire
3. Attain supporting documentation
4. Consult with Your Surgeon
5. Letter of Medical Necessity/Arrangement of financing
6. Verification of benefits/prepayment
7. Schedule surgery

If You Get a Denial for Benefits for Weight Loss Surgery
Occasionally, insurance companies will deny an initial application for benefits, even when well substantiated, and well within the consensus criteria recommended in the NIH report. Sometimes they cite a technicality of your specific policy. It may be difficult to figure out why there was a denial. Be cautioned that you may have only so many opportunities for appeal, and they should not be wasted. If you get a denial, please speak to our insurance experts at CRMC Lifestyles Management. You and your surgeon may decide to change something and resubmit. However, there are certain cases when we can no longer help.

If your insurance carrier remains unreasonable, you may wish to seek legal assistance in obtaining good faith coverage of your medical needs. For information on legal assistance, you may want to check with the Obesity Law and Advocacy Center.

If your employer's health insurance does not cover weight loss surgery, you may still have options. For example, your spouse's plan may provide coverage and you may be able to sign up during the next open enrollment period. Or, you may have success making an appeal to your employer to upgrade their plan or to change insurance carriers who do provide benefits for weight loss surgery. More and more employees need to make their wishes known to their employers. More and more employers need to put pressure on insurance companies to provide reasonable ways to get their employees benefits for weight loss surgery. Please be a voice for all the good people that need this surgery.

Advance Payment Option
If you do not have insurance, if you follow your insurance company's guidelines for approval and are denied, or if you'd prefer to bypass the insurance approval process, we may have a financing option that may enable you to make your weight-loss goals a reality. At this time, we have a program specifically designed for LapBand financing. (See below.) At this time we do not have cash or out of pocket options for Gastric Bypass, but if you happen to be interested CRMC Lifestyles Management and the Rocky Mountain Weight Loss Surgery Associates will discuss this with you carefully. You may be willing to arrange your own financing for either procedure that we offer.

Remember that tax law will usually allow weight loss surgery to be tax deductible. Talk to your accountant or tax professional.

Financing the Lap-Band
Some insurers and certain plans will pay for Gastric Bypass and yet will not pay for the LapBand. We anticipate more coverage for the LapBand over time, but it is often a cash pay or self pay surgery. Please check with CRMC Lifestyles Management insurance experts, your insurance may cover the Lap Band. Some patients choose to pay for the operation themselves, often when they discover that their insurance company will not pay for the LapBand. We encourage you to try not to let your insurance coverage issues dissuade you from having the LapBand if you believe it is the right operation for you. The LapBand is more affordable and you may be able to finance it.

In cooperation with United Medical Center, the anesthesiologists, the psychologists, Rocky Mounth Weight Loss Surgery offers special packages for cash patients, which include all the needed services, at a substantial discount. This package deal includes the surgery, the overnight stay (if necessary), the post-operative imaging, and six months of follow-up and band adjustments.

You may want to arrange your own financing, but the company that manufactures the LapBand®, Inamed has nationally available financing option that we can tell you about.

Find out more about LapBand financing at their website: Http://www.lapband.com/lapband/costsandinsurance.do

* Cash pay patients and Complications. Please think very carefully about and speak to your insurance carrier and your surgeon if you plan to pay cash for your operation in regards to what may happen if complications occur. You may be and probably will be financially responsible.

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