Before you consider weight loss surgery as an option in the management of your obesity, we suggest that you contact your insurance company to verify that bariatric treatment is covered by your policy and that the MUSC Bariatric Center is part of your coverage.  Some policies exclude all types of weight loss surgery.  If there is no specific exclusion, a representative of the insurance company is generally contacted to verify whether the benefit of weight loss surgery coverage is actually available. Some insurance companies will be up front and say yes or no, but others will not even say if it is a covered benefit until all documentation is in and a determination has been made about medical necessity.

One important point to keep in mind is that obesity and morbid obesity are considered two different health conditions. Many plans will exclude treatment for obesity but will cover treatment for morbid obesity. It is important to be very specific in the language you use when dealing with insurance companies. Another important point to keep in mind is that not all representatives of a particular insurance company will be as knowledgeable about their policies as others. Some will not even know what morbid obesity is and you may be misinformed about coverage for your weight loss surgery. It is important to check more than one source to verify that what has been told to you is valid.

Insurance instructions and approval for surgery and bariatric treatment
Benefit Guidelines
Many insurance companies have their own specific benefit guidelines, describing whether weight loss surgery treatment for morbid obesity will or will not be covered. If it is a covered benefit, they have specific requirements that must be met before they will authorize benefits for the treatment. The process can be long and difficult requiring much effort on the part of the patient and the doctor’s office. 

The following is a basic list of what insurance companies are requiring in order to determine if bariatric treatment for morbid obesity is a covered benefit.

**PLEASE NOTE THAT WE WILL NOT BEGIN THE PRE-CERTIFICATION PROCESS UNTIL YOU HAVE PROVIDED OUR OFFICE WITH ALL REQUIRED INFORMATION:

• Documentation of Dieting. Many insurance companies are asking for documentation of dieting. This can be in the form of diet records from commercial weight loss programs, medical records from your primary care provider or receipts for weight loss programs. Some insurance companies have gone as far as requiring a 6-month daily record of eating habits.
  
  
• Documenting Exercise Attempts. Many insurance companies are asking for documentation of exercise attempts. This can be in the form of attendance records at exercise programs, receipts for gym membership and records from rehab appointments.
  
  
• Psychological evaluation. Many insurance companies are now requiring some sort of psychological evaluation. This can be in the form of a psychological screen to test your state of mind and ability to cope with surgery. Some insurance companies are requiring an actual evaluation from a psychologist or psychiatrist.
  
  
• Medical records. Medical records are required, and must be submitted with all other documentation prior to the insurance company making a determination.
  
  
• Letter of Medical Necessity. This is a letter usually written by your surgeon that outlines your medical, diet and exercise history and your current state of health. It is the summary of all your information that makes the case for why surgical treatment for your morbid obesity is medically necessary. This letter is usually submitted with all your other documentation.
  
  
• Predetermination. Once all your records are gathered and sent into the insurance company with the letter of medical necessity, the insurance company goes through a review process to determine if they will approve this benefit for you. At this point they may either ask for more documentation, approve this benefit for you or deny this benefit to you. If you are denied, most insurances have up to 3 appeals that they allow you to make. It is important not to waste these appeals and make sure all documentation is complete prior to filing an appeal. It is also important not to give up during the appeals process as many initial denial decisions are overturned in later appeals.
  
  
• Pre-certification. If your benefits for treatment have been approved, a final process of pre-certification through the insurance company is made, in which the scheduling of your operation, the surgeon you will be working with and the facility at which you will undergo the procedure are determined. Pre-certification generally must take place within 90 days of predetermination to be valid.

Co-pay and Co-insurance
Bariatric surgery is covered by many insurance policies, and the amount that it costs depends upon the type of policy and its terms, as well as any contractual arrangement with the hospital. Insurance coverage comes in many types, and coverage really cannot be predicted, since it varies from policy to policy, even when issued by the same insurance company. If you wish to come to us for evaluation and surgery, we perform the insurance authorization and approval process without charge. With specific policy information and approval, we can obtain your out-of-pocket expected costs before you schedule surgery.

University Medical Associates, the physician billing office, requires payment of your co-pay and co-insurance 14 days before surgery is performed.  UMA will call and state the estimated co-insurance amount to be paid. We must, however, wait for such approval or have the financial commitment of the patient, prior to scheduling surgery.
The cost of the operation includes:

• Hospital charges – Medical University of South Carolina
• Surgeon's fee
• Surgical Assistant's fee
• Anesthesiologist's fee
• Laboratory charges
• X-Ray charges
• Consultant fees - as necessary

What if my insurance won't pay or if I choose to pay myself?