by Melinda D. Maryniuk, MEd, RD, CDE
Trying to manage your weight can be a lot of work. You pay close attention to eating right and exercising more, but the science shows us that for many people, that’s just not enough to successfully lose weight and keep it off. [insert a video here]
As Dr. Sean Wharton points out, there are three things that have been shown to be effective for losing weight and keeping it off in the long-run—medications, bariatric surgery and cognitive behavioral therapy (or CBT). Unfortunately though, insurance often doesn’t cover these options (or there are long wait times to receive care, which is particularly true for bariatric surgery) even though their effectiveness is well-documented. What can you do?
Educate yourself. Obesity is a chronic disease and it’s recognized as such by the American Medical Association, the Canadian Medical Association and the World Obesity Federation. Many insurance companies haven’t incorporated this reality into their benefit plans and may benefit from being educated about why medications and surgery are some of the few proven long-term treatments for obesity.
Learn about all the benefits offered by your health plan. Read the benefits handbook or explore the member services section of the website. You may also talk with the benefits manager in the Human Resources department for your employer. You may be surprised to learn that your insurance plan covers more services than you might have realized– for example, most insurance plans have benefits for weight loss classes, gym memberships, and diabetes education classes.
Keep good records. There may be times when you need to document “medical necessity”. That means, you show proof that you need something special or extra for your health. For example, if your weight is impacting your health (causing sleep apnea, joint pain or elevated blood glucose values, for example), your physician may have a stronger case to make about why a medication or procedure should be covered.
Don’t take “no” for an answer. If a treatment you are interested in is not covered, sometimes exceptions can be made. Explore these steps:
- Review your healthcare options including your and your spouse’s plan coverage and evaluate if a plan change is needed during the Open Enrollment period. Also keep in mind you can explore the Healthcare Exchange for additional plan options.
- Learn the reason why a treatment may not be covered. Is it a decision by the insurance company or your employer?
- Ask about the formal exception process. Each health plan has a standard appeals process. Review your “evidence of coverage” for appeal steps. Most insurance companies allow you or your provider to file an appeal within 180 days. When writing the appeal focus on all the medical reasons this treatment should be covered and provide as much documentation as you can.
- Talk with your doctor or healthcare provider to establish a strong reason why you may benefit from a different treatment. It’s usually best to meet with your healthcare team in person to discuss this and be prepared to show reasons why this is important to you for medical and personal reasons.
- Remember while your insurance company may have denied the coverage that doesn’t mean you can’t receive the treatment/medication. You can choose to pay out of pocket, some providers may be willing to provide the treatment without going through insurance. Talk with your provider about setting up a payment plan for services. In addition, for those enrolled in a “Healthcare Flexible Spending Account “ (FSA) pretax money can be used to pay for your qualified healthcare needs.
Gather Resources. In addition to reviewing the handbook to understand your insurance benefits, explore additional resources. The internet is a helpful source of information that you can search in more depth to help explore coverage for specific products such as a new medicine or a procedure.
- If you are interested in Weight Loss Surgery and have been denied: What to do when you’re denied (bariatric) weight loss surgery. Read more here.
Getting coverage for the best treatments available often requires the three P’s: patience, persistence and paperwork. Remember—your weight is not your fault. You deserve the best care possible and it’s worth the extra time and effort to ensure that you receive it.
Watch Dr. Wharton talk about advocating for yourself here:
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