Insurance Issues

Why does the insurance approval process take an extended amount of time?

Once your consultations are concluded, and all necessary reports are obtained, the typical procedure involves your doctor taking 1-2 days to draft and send a letter to your insurance carrier, initiating the approval process. The timeframe for receiving a response is subject to variation, ranging from approximately 3-4 weeks or even longer if diligent follow-up is not maintained. Many treatment centers employ insurance analysts who regularly follow up on approval requests. To expedite the process, it is advisable to contact the claims service of your insurance company approximately one week after the submission of your letter to inquire about the status of your request.

How can insurance companies deny payment for a life-threatening disease?

Payment denial may occur due to a specific exclusion in your policy concerning obesity surgery or the “treatment of obesity.” However, such exclusions can often be contested, particularly when the surgical treatment is recommended by your surgeon or referring physician as the most effective therapy for alleviating life-threatening obesity-related health conditions, which are typically covered.

Insurance payment denial may also be attributed to a perceived lack of “medical necessity.” Medical necessity is established when a therapy is deemed essential for treating a serious or life-threatening condition. In cases of morbid obesity, alternative treatments such as dieting, exercise, behavior modification, and certain medications may be considered available. Denials based on medical necessity often revolve around the insurance company’s request for specific documentation, such as 1 to 5 years of physician-supervised dieting or a psychiatric evaluation, demonstrating unsuccessful attempts to lose weight through other methods.

What can be done to facilitate the approval process?

To enhance the approval process, it is advisable to compile all necessary information (diet records, medical records, medical tests) that your insurance company may require. This proactive approach significantly reduces the likelihood of denial due to a failure to provide “necessary” information. Particularly valuable are letters from your personal physician and consultants attesting to the “medical necessity” of the recommended treatment. When multiple physicians concur with the same findings, it strengthens the case for the medical necessity of surgery.

Upon submission of the letter, maintaining regular communication with your insurance carrier is crucial. Regular inquiries about the status of your request, along with potential assistance from your employer or human relations/personnel office, can help navigate through any unreasonable delays in the approval process.