Weight loss surgery is covered by Blue Cross Blue Shield of Oklahoma, however it must be included in your specific insurance for it to be covered.
Blue Cross Blue Shield of Oklahoma plan types and whether they cover bariatric surgery are listed below:
Does Oklahoma Medicaid cover bariatric surgery?
We all know how difficult it is to lose weight. There are numerous programs and treatments available to assist us in losing weight, but they all come at a cost. We’re paying some Oklahomans to lose weight, which you probably didn’t know.
Soonercare, Oklahoma’s Medicaid program, allows eligible patients to have bariatric surgery on our cost.
Nine Oklahomans have had lap band or gastric bypass surgery in the last five years. The cost of the operations alone was more than $85,000. Pre-op and post-op care are not included.
Before undergoing weight loss surgery, Soonercare patients must meet a comprehensive number of requirements, including having been diagnosed as obese for at least five years, having attempted other methods to lose weight, and having another health concern as a result of their weight. They must also lose 5% of their body weight before undergoing surgery.
While tax monies are used to pay Soonercare, the federal government provides 64% of the funding. The remaining 36% comes from state funds.
How much is gastric sleeve in Oklahoma?
A Gastric Sleeve (inpatient) costs $10,650 to $11,891 in Oklahoma, according to MDsave. Those with high deductible health plans or those who are uninsured can shop, compare costs, and save money.
Does Blue Cross Blue Shield cover bariatric surgery?
Yes, depending on the type of insurance policy you choose, Blue Cross Blue Shield will cover bariatric surgery. It’s important to remember, though, that even if you pay the monthly, you’ll only get genuine coverage if you submit all of the required paperwork for approval.
- Call your insurance or speak with your employer to find out if Blue Cross Blue Shield covers bariatric surgery and if there are any exceptions in your plan. Examine the exclusions section of your health insurance policy to see if weight loss surgery is a covered benefit.
- Types of coverage: Even if your Blue Cross Blue Shield plan covers bariatric surgery, you should know what other weight-loss operations and obesity therapies are covered. The amount of coverage you get depends on the type of insurance you have and the perks you select.
- Out-of-pocket charges: Your individual health plan may include co-pays, deductibles, and maximums for out-of-pocket expenses, even if your Blue Cross Blue Shield covers bariatric surgery. Each calendar year, these restrictions are reset, so check with your insurance ahead of time for more information.
How much is gastric bypass surgery in Oklahoma?
When you take the median of the 42 medical providers who provide Bariatric Surgery operations in Oklahoma City, OK, you’ll find that a Bariatric Surgery costs $9,341.
What if your insurance doesn’t cover bariatric surgery?
After you’ve weighed your alternatives and decided that bariatric surgery is the best option for you, you’ll want to know how you’ll pay for it. Many insurance companies acknowledge the importance of obesity and its health repercussions, and will pay for weight loss procedures if you meet plan-specific eligibility requirements.
How to verify your own benefits
Although the staff at your surgeon’s office will verify your benefits as a courtesy, it’s a good idea to call your insurance carrier to confirm coverage and restrictions. You can also read the coverage documentation that your employer and/or insurance company have issued to you.
You’ll want to know if bariatric surgery is covered; if it isn’t, it’ll most likely be included under “obesity” or “weight reduction surgery” in the plan’s exclusions. Bariatric surgery is commonly described as being covered if it is medically required, but this is only partially accurate because it must also be a covered benefit.
You’ll want to know what’s required once you’ve confirmed that your plan covers bariatric surgery. Each plan has its own set of criteria and regulations for determining medical necessity to your insurance carrier’s satisfaction. Although your carrier’s medical policy is the most typical place to obtain benefit criteria, your employer may have an addendum document (“summary plan document/description”) that explains extra or other requirements for particular treatments. Because the requirements of the medical policy are often superseded by a summary plan document, it’s crucial to know if an addition like this applies.
Medical necessity vs. coverage exclusions
Despite the fact that you may meet basic and widely accepted medical necessity requirements, your insurance company is not compelled to cover bariatric surgery. Your insurance will not consider you for coverage if weight loss surgical services are designated as an exclusion, regardless of your BMI or concomitant conditions. The denial rationale does not imply that surgery is not medically required, but rather that they do not give this form of coverage, for which there is no appeals process.
Cash paying for surgery
There are alternative solutions open to you if your insurance does not cover bariatric surgery. Consultations, nutritional counseling, pre- and post-operative tests, labs, and follow-up visits may be covered depending on the plan language, but surgery is not. Verifying your benefits will assist us in estimating potential costs for you during your appointment.
How to meet insurance criteria
You’ll meet with a surgeon for a consultation once your benefits have been validated. Your height, weight, and BMI will be recorded, as well as any concomitant conditions and previous unsuccessful attempts at non-surgical weight loss. If your plan calls for a medically supervised weight loss program, you’ll meet with a dietitian on a monthly basis for the duration of your treatment.
Because a psychological clearance is the most prevalent insurance criterion, you should make an appointment with a mental health specialist who will assess your candidacy for bariatric surgery. It’s crucial to rule out psychological issues, any type of disordered eating, a lack of competence to provide informed consent, and a failure to follow pre- and post-surgical instructions.
Insurance authorization process
The authorisation process can commence if all pre-surgical and insurance requirements have been satisfied. Your pertinent medical records will be compiled and sent to the clinical review department of your insurance company. A determination can take up to four weeks, but it is more common to receive one in two weeks. You’ll be notified of the approval or denial once we hear from your insurance. Surgery can be planned or confirmed once you’ve gotten approval.
If your operation is denied, we will examine the decision and follow the measures provided by your insurance company. Denials can occur for a variety of reasons, including a lack of paperwork or a lack of agreement on criteria that are ambiguous or open to interpretation.
Appeals
Because appeals deadlines may be approaching quickly, it’s critical to properly evaluate denials.
As a first step in this process, a peer-to-peer option is usually available. A peer-to-peer meeting is a prearranged meeting between your surgeon and the medical director of the insurance company to address the denial. When this conference is feasible, it’s quite beneficial since we can get precise input from a reviewing authority about what additional the insurance company expects us to provide or what they want you to accomplish in order to qualify. At the time of this debate, the rejection may be affirmed or reversed, but it’s usually just a tool for moving forward with the appeal.
If an appeal is necessary, we will obtain any additional documentation that was previously overlooked. If more tests or office visits are needed, they should be planned as quickly as possible to ensure that they are completed before the appeal time expires.
There could be several stages to the appeals process. A second- or third-level appeal can be requested if necessary, with the final step typically including submission to an outside party for review. Because external review organizations are not linked with our office or your insurance provider, they can conduct an unbiased assessment of your clinical documentation.
What can I do to ensure approval?
A patient health history questionnaire will be given to you prior to your session. Because it will be translated into your medical record, which will be evaluated by the insurance provider, it is critical that you fill this out entirely and truthfully.
Bring a copy of any paperwork (medical chart notes, personal records, logs, or receipts) from past weight loss attempts, whether by diet, exercise, or medical supervision, to be reviewed and scanned into your chart.
If you’ve had a previous weight reduction treatment, you should get copies of your operative report, as well as pre- and post-surgical visits, to demonstrate your commitment to follow-up and adherence to any suggestions provided by your previous practitioner.
The single most important thing a patient can do to increase the chances of their insurance company approving their claim is to follow the medical policy’s rules to the letter (or Summary Plan Document, if applicable). Medically supervised diets are generally need to be followed for several months and should be spread out by about 30 days. Failure to keep scheduled appointments for several months in a row will almost always result in denial, delaying surgery or forcing you to restart the prescribed regimen from the beginning.
Does Medicaid cover gastric sleeve?
Lap-Band Surgery, gastric sleeve surgery, and gastric bypass are all covered by Medicaid in most circumstances. These are not just easily funded by Medicaid, but they are also among the most frequently recommended operations. In some cases, these are deemed medically necessary for the patient’s survival and well-being.
Gastric bypass surgery reduces the size of the stomach while also bypassing a portion of the intestine. As a result, you eat less and the food is delivered directly to the lower intestine. Nutrient and calorie absorption is reduced as a result of the bypass. As a result, it reduces food intake while also assisting in weight loss. The top region of the stomach is covered with silicone bands and balloons in Lap-Band surgery. This limits the amount of space available for food storage. In addition, the stomach’s entrance narrows. The procedure is less invasive than others because it is performed laparoscopically. It is also desirable because it is simple to reverse and the band can be changed. Finally, a sleeve-shaped, smaller stomach is created with gastric sleeve surgery. Because there isn’t much room for food to sit, it passes through the intestines quickly. As a result, it also reduces food intake and calorie absorption.
What are requirements for gastric sleeve?
The following are the minimum prerequisites for gastric sleeve surgery:
- A BMI of 30 to 39.9 combined with a major obesity-related health issue such as diabetes, high blood pressure, sleep apnea, high cholesterol, joint difficulties, and so on.
Does Soonercare pay for gastric sleeve?
Under certain situations, as outlined in this provision, the Oklahoma Health Care Authority (OHCA) will cover bariatric surgery. Obesity alone does not qualify for bariatric surgery coverage. OHCA must contract with bariatric surgery facilities and their providers.
How much do bariatric surgeries cost?
The cost of bariatric surgery can range from $15,000 to $23,000. The majority of people who have bariatric surgery are able to do so because it is a covered benefit under their health insurance plan. Our insurance consultant will meet with you on your first visit to our bariatric program. Their job is to explain your coverage and any potential out-of-pocket expenses. There are a few other things to keep in mind about your insurance and bariatric surgery:
How can I get insurance to cover gastric bypass?
How to get insurance to cover weight loss surgery
- Have a BMI of 40 or more, or a BMI of 35 or more plus a comorbidity like diabetes or hypertension.
- Pass a psychological exam to see if you’re emotionally ready for weight loss surgery.