Managing a Bariatric Surgery Insurance Denial

You spent hours preparing for your bariatric procedure by putting together all the required documentation from your insurance company, attending medical weight loss programs and discussing coverage with both the office and your insurance company. Now that surgery is behind you, you can turn your attention to the next phase of your bariatric life – the postoperative weight loss phase.

Except, insurance has denied your claim. What exactly do you do now?

First and foremost, it’s incredibly important you know this is a not an uncommon occurrence. You can imagine the volume of claims that come into a major insurer every day. It becomes clear that some will be denied simply due to clerical errors. Oftentimes, it is a simple oversight that means the difference between paying for your surgery or not.

Once you are appropriately calm and ready to move forward in the appeals process, it is very important you call the insurance company and find out exactly why the claim was denied. They must provide you with their reasoning, and you should also ask for a copy of the denial in writing.

From there, we encourage you to contact our office to go over your paperwork and see if it was simply an oversight that caused the denial. Our billing specialists have dealt with this situation before and can help you understand exactly what is needed to get the coverage you expect.

If your insurance is through the company you work for, an appropriate next step is to involve your HR manager who can help advocate for coverage.

On occasion, there may be a problem with the documentation you submitted, or the insurance company may continue to insist on a denial. At this point, you have the option to appeal this denial. Usually, insurance companies review your claim with an impartial board of administrators and clinicians who review its validity. In the worst-case scenario, there’s always the possibility to take a denial to the state insurance regulator.

Fortunately, it rarely comes to that.

How about preventing a denial in the first place?

Legitimate denials are usually because of missing documentation that hasn’t been provided to the insurance company. As such, it is important to understand your plan’s requirements and criteria for coverage well prior to surgery. While we can help you with this, ultimately it is up to you to verify with your insurance the procedure will be covered.

This is especially true for Medicare patients. Medicare does not have a pre-authorization process for bariatric surgery, and as such you must make sure your paperwork is complete and properly submitted for coverage.

One of the biggest misconceptions that some patients have is that because their friend or family member had the same insurance company, and were covered for surgery, they will be covered as well. This is not necessarily the case as different plans, even under the same corporate umbrella, may vary dramatically as to what they cover and what they exclude.

The Bottom Line

With the above being said, we rarely see denials from complete and proper documentation. We also encourage you to take advantage of our knowledgeable billing specialists to help ensure the documentation submitted is what the insurance needs.

You can learn more about the insurance we accept for bariatric surgery as well as information on Medicare coverage by visiting the following pages:

Main Office

3 Mobile Infirmary Cir, Suite #212,
Mobile, AL 36607

Springhill Medical Center

3715 Dauphin St. Building 2 Suite 6D
Mobile, AL 36608