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Michael Schweitzer, M.D., F.A.C.S |
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Experience, low
complication rate, excellent outcomes….this is not the time to go to any surgeon
on an insurance list. Morbid Obesity Surgery is considered to be Major
Abdominal Surgery. Laparoscopic approaches vary and so do the results. I was
the first in the Mid-Atlantic area to perform Laparoscopic Gastric Bypass,
and the first in Maryland/DC/Northern |
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Insurance The number 1 issue is diet history!
Some insurance companies require a recent diet history in the last 2 years.
Some do not require it at all. If they do require recent dieting, it is usually
6 months of documentation and at least once a month visit in most
cases. If you can not figure out your policy please call your insurance
company and our office for help. For example: Aetna requires 6 months
of supervised diet in the last 2 years or 3 months of a comprehensive
diet/exercise program ( the Johns Hopkins Weight Management Center has a 3
month program for Aetna patients). Another Example: Blue Cross may
accept 2 separate diet programs of 3 months each versus 6 months. Some Blue Cross insurance plans may not
require any recent diet program. Links: Johns Hopkins Weight
Management Center Aetna Morbid
Obesity Policy (I use Aetna as an example since you can easily go to
their web site for the policy, other insurers may also do this as well) The 6 month diet history that is
required by some insurance companies may require a doctors note from each
visit or proof of attendance at Weight Watchers, Jenny Craig, etc(cancelled check,etc..). The If you are unsure then I suggest you
start a supervised diet program with your physician (must include documented
weights and counseling) or our weight management program even before your first
visit. Lastly, insurance companies are
constantly changing the rules so it is important to check with your actual
insurance company policy. After your initial consultation and if you
qualify, we will send a letter to your insurance company outlining why it is
medically necessary for you to undergo morbid obesity surgery. Some of the
qualifications include: 1.
You must have a
body mass index of 40 or bmi 35 or greater with an
obesity related significant medical problem 2.
You must have
tried dieting in the past 3.
You must have a
stable psychological profile (ex: if you are currently depressed then you
will need to be undergoing treatment and deemed medically stable for surgery) 4.
You must accept
that this is major surgery with major risks 5.
You should have
a supportive family and/or friends Many insurance companies require
documentation of diets (some even require physician only supervised diets)
that you will need to submit yourself to their claims department. It depends
on the insurance company how many months of diets you need supervised. It is
best to call them since they change over time. I also suggested that you make
a typed list of every diet and exercise program you have every done in your
lifetime along with the increase in your weight over time. You should also
have your primary care physician write a letter of support and any other
physician that will document losing weight will help relieve one of your
medical conditions (for example: gastric bypass induced weight loss in
approximately 85% of patients will resolve type II diabetes, therefore a
letter from your PCP or even an endocrinologist stating your type II diabetes
is related to your weight will be beneficial). Mail this to your insurance
company along with a brief letter stating why you feel it is medically
necessary for you to have surgery. You are your best advocate and by being
involved it will be less likely denied then if you are not involved at all (I
can not stress this enough). You should keep copies of everything and
ask for names when talking to representatives. Please be patient since it can
be a long process. It is a good idea to call your insurance company 3 weeks
after your initial visit to see if they received our letter. After your initial visit and before surgery
you will need to see our dietician and psychiatrist.. There is a Maryland law covering obesity
surgery but if you have a plan that is self-insured (your card may say for example
Aetna but the plan may be self insured and so call your benefits office to
find out) or the employer has under 50 employee’s then it falls under federal
guidelines and they can exclude if the want to. You can find more info at www.obesitylaw.com . Please realize just because you can get
authorization but it is not a covered benefit they will not pay. You should
also realize that they may tell you they will not pay unless deemed medical
necessary but that is okay since that is the only reason anybody undergoes
obesity surgery and this just means you must first see me in consultation.
Clarify with the insurance personally that if it is deemed medically
necessary then it is a covered benefit. This is the purpose of us sending a
letter to your insurance carrier. .****If you have
Out-of-Network option with your health plan and I am not In-Network you still
have the right to see me. You paid for the Out-of-Network option (ex:PPO, POS, HMO with out of network, 2 tier, 3 tier,
etc..), and therefore, do not let an insurance representative tell you
otherwise. ****** Deductible The policyholder must pay this amount of
money per plan year before insurance will start to provide any payments. Example: Mary must pay $500 a year (per
person) deductible before her insurance will start to pay for some or all of
her medical expenses. Co-pay Many policies require a co-pay with each
visit (surgery, hospital admission, ER, and others may also have a co-pay
depending on your policy). It may be as little as $5.00. Indemnity or Coinsurance A policy may require you to pay a certain amount of the medical bill after the deductible and co-pay. Point of service (POS) and PPO policies allow you to go out-of network but usually not at full coverage. HMO will not usually cover out of network expenses beyond their discount payment to the surgeon (you need to ask). You must find out if your surgeon is in-network or out-of-network. |
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Example: Mary’s gastric bypass was done at
an in-network hospital but with an out-of network surgeon whose fee is $5500.
After meeting her deductible for the year she has 80% coverage by the
insurance company for the customary charge of the surgeon’s fee. She will be
responsible for the 20% and anything over the customary charge. If the
insurance company tells her the customary charge is $5000 then she will be
responsible for 20% plus the $500 difference. The customary charge represents
what the insurance company deems is the usual charge in the community. This
is not the amount the insurance pays for an in-network physician or HMO
payment. You must call and ask specifically what is the customary charge for
the surgeon’s fee associated with that surgery (you will need the CPT code
for that surgery*****this is where you need to argue that the customary
charge or fee is higher than the discount payment to in-network doctors. You
can tell them you called the other Bariatric Surgeon's offices in Maximum Out-of Pocket Expense Many PPO and POS plans have a maximum
out-of-pocket expense for the customary charges in that plan year. Example: John’s surgeon charges $3000 for a
gallbladder removal. He has a maximum out-of-pocket expense of $1000 per year
that includes deductible and coinsurance. His co-insurance covers 60% and his
deductible is $500 but he will only have to pay $1000 total since that is his
maximum and the insurance company stated to him that the customary charge for
a gallbladder is $3000. Please Call Your Insurance Company!!! You need to know if deemed medically
necessary does your plan cover morbid obesity surgery You should find out
your: 1)Deductible 2)Co-pay 3)Out-of-Network benefit for the surgeons
fee 4)Co-insurance
(ex:80/20 or 70/30, etc) 5)Maximum out-of-pocket expense (ex: $1000) 6)If you are in a HMO and surgeon is out of
network what will they cover? They may since wait list are long and if you
agree to the difference in surgeons fee the hospital and anesthesia are
covered since they are in-network in most cases. You will need to know the CPT codes the
surgeon will bill (see below) 43644 – Laparoscopic RNY Gastric Bypass 43770 - Laparoscopic Lap Band code There is no specific laparoscopic Duodenal
Switch with BPD cpt code currently in place so
when calling your insurance company tell them 43659 & 43845 (open
duodenal switch with bpd code). There is no specific laparoscopic sleeve
gastrectomy cpt code currently
in place so when calling your insurance company tell them 43659 & 43843 43659 – unlisted laparoscopic stomach code (we submit a letter with the
open and laparoscopic code but will bill in most cases using the unlisted
laparoscopic code) 43846 – Open RNY Gastric Bypass 43848 – Revision from a vertical banded gastroplasty
to RNY Gastric Bypass ***All of this above is subject to change,
it is therefore important that you ask your insurance company directly along
with asking us after your initial consultation.
********************************************* Michael Schweitzer,
M.D., F.A.C.S. Associate Professor of
Surgery The Director of Minimally
Invasive Bariatric Surgery Department of Surgery 4940 Eastern Avenue Phone: 410-550-3345 email DrSchweitzer@yahoo.com web site www.smallscar.com |
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Johns Hopkins Bayview Medical Center | Johns Hopkins Medicine |
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© The medical information provided in this site is for education & information purposes only. The information provided is not a substitute for a professional medical opinion. If you have a medical problem, please contact your doctor or health care professional. Content copyright © 2000 Michael Schweitzer, M.D. All Rights Reserved. Republication or redistribution of any content is expressly prohibited without the prior written consent of Michael Schweitzer, M.D.