Insurance Coverage for Surgery
Sometimes surgery is needed suddenly and there's not a lot of time to think about how to pay for it. And even if it's something you know about ahead a time, it's not always easy to prepare for the financial aspects. That's why it's important to talk with your insurance company as soon as possible. Coverage for some surgeries can vary by employer or by state (in the case of Medicaid). Some procedures must be pre-authorized before surgery, which can take a while, so it is important to check beforehand about the approval process.
Here are some things you should know about insurance coverage for surgery:
- There is a "certificate of coverage" that your insurance company is required by law to give you. If you don't have one, consult your employer's human resources or benefits administrator or ask your insurance company directly. And be sure to take the time to read it and ask any questions you have to understand exactly what it's saying.
- In order to gain access to coverage, you may need to provide your medical records. Coordinate with your doctor's office and your insurance company regarding all communication and documentation related to your case.
The Insurance Appeals Process
For certain procedures, particularly ones relating to weight loss (bariatric) surgery or plastic (reconstructive) surgery, you may have to try several times for pre-authorization. Even if your initial request is denied, you still have the option to appeal the insurance company's decision. This process allows you to address each one of the reasons your insurer gives for not approving the procedure. But it's important to reply quickly.
- At this point, it's recommended to get the advice of an experienced insurance appeals attorney or insurance advocate to help you navigate the complex appeal process. Some insurers limit the number of appeals you may make, so you need to fully understand the rules for appeal under your plan and be prepared to make a strong argument.