How Does Insurance Impact Weight Loss Surgery Cost in Alabama?

First, if you are taking steps to improve your health through weight loss surgery, congratulations! Making any lifestyle change for your own betterment is tough, so good on you for trying to improve things! However, the entire process is an uphill battle. Not only, are you having to face an emotional struggle with friends and family, and a personal struggle with possible food addiction, you are also going to have to mitigate a financial and logistical struggle on top of everything else.

The cost of weight loss surgery alone is about as much as you would expect to pay for a recently used vehicle, not to mention the various therapies involved, the hospital stays if there is one, and other fees for yourself, friends, and family that accrue over time.

One of the ways that can ease any financial burden that may come from the procedure is to have partial or total insurance coverage for the procedure and the hospital stay.

But is there even any coverage for weight loss surgery in Alabama? Are there any specific requirements or policies that are involved?

 What Qualifies You For Weight loss Surgery coverage in Alabama?

 According to Obesity Coverage, a site dedicated to answering inquiries about weight loss surgery and insurance, Blue Cross/Blue Shield, Alabama’s only insurance company on the market, the procedures that are being covered are:

 Laparoscopic Gastric Bypass

Open Gastric Bypass Surgery

Gastric Banding – including the Lap Band and Realize Band

 Now that we know what procedures are being covered, we need to know how much they cover it, and what sort of requirements need to be met before the procedure can even be done. The good news, is that in the state of Alabama, these procedures are covered partially if not fully by the BlueCross/BlueShield insurance company.

 The basic prerequisite steps that need to be taken before you could be approved for weight loss surgery coverage by BCBS Alabama is as follows:

  • Body Mass Index (BMI) of 40 or greater OR…
  • BMI 35 or greater with a co-morbid condition, including but not limited to HTN on optimal drug therapy, cardiovascular disease, diabetes (must be treated with insulin or oral agents), pulmonary hypertension or severe obstructive sleep apnea (RDI of 50 or greater).
  • Documentation of participation in a physician supervised program of nutrition and increased activity including dietitian consultation, low calorie diet, increased physical activity and behavioral modification. Program must be for six consecutive months and must be within previous 12 months of request for surgery. Documentation of program participation must appear in the medical record by the attending physician. Records must include comments by the physician regarding patient progress or lack of progress OR acceptable with medical record documentation of medical supervision are: Weight Watchers, LA Weight Loss, Jenny Craig, EatRight etc. Not acceptable are self-directed programs such as joining a gym, Atkins diet, calorie counting, low fat, cutting back, internet programs, etc.
  • Active participation and documentation of non-surgical methods of weight loss.
  • Diagnosed as morbidly obese for 3 years or more in medical records. A letter from the PCP and dated photographs will be considered in lieu of recorded heights and weights.
  • 18 years of age
  • Primary Care Physicians Letter (PCP Letter)
  • Consult and Recommendation for surgeon from bariatric surgeon.
  • Must stop smoking at least 8 weeks prior to surgery.

 However, it is important to note that since Alabama tends to lean politically on the conservative side of things, they put rights of individual businesses and employers over the rights of the entire collective, meaning that when the Affordable Care Act was put into place, companies and employers were given expressed permission to opt out of certain types of insurance coverage by the state.

 Long story short, employers can opt out of covering weight loss surgery if they so choose.  Which most likely leaves you wondering…

 What Do You Do if You are Denied Coverage?

 Employers are busy people, and chances are they are more likely to pay attention to short term financial losses over long term productivity benefits. Or, maybe the coverage request might not have made it to the person in charge of this sort of thing?  People make mistakes and they do happen.

But if you have double and triple checked that you have your documentation in working order, they might not just be aware of your circumstances, or why weight loss surgery is more than just a vanity or a “short cut. “

If that’s the case, you might need to focus more on gaining advocacy for your cause, and there are groups that exist out there for these reasons. The Obesity Action Coalition exists to educate on the behalf of and advocate for people who are fighting for weight loss surgery coverage by their employer.  Check them out, if you feel like you are having trouble getting heard by your employer and try a few of these steps that they recommend if you aren’t getting what you need.

To Do List if Denied:

  • Speak with your human resources department – is your company self-insured?
  • Find out if you meet their criteria.
  • Make sure it is documented that you meet their criteria.
  • Work with your surgeon/program to complete a peer-to-peer review if your company covers surgery and you meet the criteria.
  • Consider hiring an advocate, such as a lawyer that specializes in representing individuals affected by obesity.
  • Educate yourself and others using the resources mentioned in this article.
  • Gather your documentation, speak with your human resources department or company owner regarding cost sharing a self-pay rate at a comprehensive program with BLIS coverage.

Conclusion

 Getting weight loss surgery coverage in Alabama can be easy for some people, and harder for others. If you keep a record of everything you need, know your rights, and have a strong supportive network of friends and family, things will get a little bit better. It won’t always happen overnight, but if you work hard, and do your best, you can overcome this, one step at a time.

http://alabariatrics.com

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