What You Need When Working with Your Provider
- Insurance provider’s name and phone/fax number
- Policy number or employer’s plan number
- Insurance company patient representative and/or contact person
- Insurance company e-mail address
- Insurance company Web site address (Many insurance providers maintain Web sites that include member information, such as coverage of medical procedures. Sometimes providers may require you sign up to view certain areas of the Web site. This process may be confusing. If so, call your provider and ask to be walked-through the sign-up process.)
Helpful Tips When Speaking with Your Insurance Representative
- Speak slowly and clearly.
- Ask for their name and write it down when they answer the call (request they spell it for you if you are not sure).
- Ask for a specific phone number and/or e-mail address from the representative and write it down.
- Ask for a hardcopy of your policy or employer’s SPD to be mailed to you with the areas regarding obesity and morbid obesity highlighted.
- Make sure you receive anything you are promised or guaranteed with your policy in writing.
- Keep a detailed record of all your documents.
- Be persistent.
- Refrain from rudeness.
- Do not demand anything.
- Do not threaten anyone.
- Do not get frustrated. If you experience an unpleasant representative, simply thank them for their time, hang up, and call back.
Reading Your Insurance Contract or Employer’s Summary Plan Description
Okay, you are halfway there now! It is important to know the details of your insurance policy. Once you have determined the type of plan you have and whether or not you have an inclusion/exclusion, you should also familiarize yourself with your plan documents. This will help you when trying to work with your insurance provider contact. As always, remember to get everything in writing when speaking with them.
Here are questions that you should be able to answer when determining coverage and the type of coverage that you have:
- What are your health insurance benefits?
- What is the definition of morbid obesity according to your plan?
- If any, what coverage of morbid obesity is listed?
- What limits and/or requirements are stated in order to receive morbid obesity treatment? For example:
– Is there a certain amount of required time you must document attempted weight-loss?
– Does the documented time have to be consecutive?
– Is your physician required to document your weight-loss attempts?
– Do you need to weigh a certain amount before treatment is performed and/or initiated?
– Is there an age requirement to receive care?
– Must you use a specific Center of Excellence or medical provider to receive coverage?
– Are there weight limitations preventing coverage?
- Is there a maximum dollar limit on your benefits?
What treatment options are excluded or specifically included?
- What is the co-payment for medical services?
- What testing is covered, such as nutritionist, psychologist, labs, sleep apnea study, ultrasounds, etc.?
- Does your insurer require weight-loss prior to surgery? If so, what percentage or number of pounds is required?
Next – The Pre-approval Process