Insurance for Bariatric Surgery
ASA accepts a wide range of private insurance plans as well as Medicare options for those who qualify. Though our program has a set of qualification criteria, insurance companies may require additional documentation to approve coverage.
While each insurance company has a unique set of criteria, patients may need to provide detailed documentation as proof that they qualify for surgical intervention for obesity. This is a general guide as to what may be expected, however please contact your insurance company to determine their exact requirements. Patients must:
- Be over the age of 18 (we do not perform adolescent bariatric surgery)
- Have a BMI of 35 or over with one or more obesity-related disease or a BMI of 40 or over regardless of associated diseases – we are participating in a clinical trial for patients with a BMI as low as 30 but insurance will not cover this procedure.
- Provide a letter of medical necessity from both your primary physician and our office
- Provide a food and exercise journal detailing past attempts at non-surgical weight loss
- Provide evidence of obesity-related diseases
- Have enrolled in a medically-supervised diet program for up to six months
- Have proof of pre-operative psychological testing to ensure their suitability for surgery
Medicare does not offer pre-approval for surgery. It may also have additional requirements beyond those listed above. If you intend to finance your procedure through a public provider, please ensure that all their qualifying criteria have been met before surgery. You may also be asked to sign a letter of financial responsibility in case of denial.
Typically, your insurance company will have a list of obesity related diseases that qualify you for bariatric surgery. The most common diseases associated with obesity are:
- Type II diabetes
- High cholesterol
- High blood pressure
- Sleep apnea
Understanding your Policy and Coverages
To simplify the insurance process and help you understand your coverage, we will perform an insurance verification. This process helps ensure that you have fewer surprises after the procedure. Even though we will be verifying your insurance, it is always important for you to contact your Insurance company directly to fully understand your financial responsibilities. There are several considerations when evaluating your insurance policy coverages.
- Your co-pay is a fixed amount that you pay for an office visit or admission to a facility. This fee typically does not get applied to your deductible
- Your deductible is the amount that you will be expected to pay before insurance kicks in. This is an annual amount that resets at the beginning of the year. If you have had other services or procedures applied to your deductible over the course of the year, you will only be responsible for the remainder of the deductible
- Coinsurance is the percentage of the services rendered that you will be responsible for above and beyond your deductible. A 10% or 20% coinsurance is not uncommon and means let you will be responsible for that percentage of the remaining cost of surgery
- Total out-of-pocket is the maximum amount that you can pay in any given calendar year under your policy. If your healthcare bills exceed this amount, your insurance company will be responsible for all covered charges
What is the difference between in network and out-of-network?
Insurance companies contract with surgical practices like ours and facilities to negotiate preferential rates on behalf of their members. In network providers typically accept lower rates, so the cost to you, the policy-holder, is lower. While you may also have out-of-network benefits, where you can choose from a wider range of providers, your cost may be higher as a result. For example, your deductible as well as your coinsurance may be significantly higher for an out-of-network provider.
Also, please be aware that the facility, surgeon and anesthesiologist will all bill separately for their services and each may have a different co-pay, deductible and co-insurance level. You should also be aware of what consultation and aftercare charges you will be responsible for, which may vary between insurance companies and policies.
Does New Jersey insurance for bariatric surgery cover revisions?
With the ever-increasing popularity of bariatric surgery, some patients experience a lack of weight loss or weight regain. As a result, revision bariatric surgery is becoming more common. Typically, an insurance company will evaluate coverage for a revisional procedure on a case-by-case basis. Keep thorough notes and enlist the help of your medical team to submit a thorough application for coverage.
For any questions you may have about bariatric surgery insurance, we encourage you to contact our office and speak to our billing representative.