Our practice will help you to qualify with your insurance company for treatment you need and deserve.
Before you schedule your consultation with Dr. Gritsus, we recommend that you call your insurance company and ask whether you have coverage for Bariatric Surgery. Although most of the plans cover Bariatric Surgery, there are still some insurance providers which have exclusions.
Most of the exclusions are in what is called "self insured" or "self guided plans". Those plans are generally administered by large corporations for their employees. For example, a company such as Verizon or ATT will self-insure their employees instead of purchasing coverage from a third party such as Aetna, Cigna or Horizon. Frequently, coverage of certain conditions may be excluded by choice of the employer. Bariatric surgery can be one of these conditions. This is wrong and descriminatory but not illegal, since self insured plans operate by a different set of rules than regular commercial insurance plans.
If your plan has an exclusion on bariatric surgery you may want to talk to your employer and ask them to include the coverage for weight loss procedures in your plan. They will be making you healthier and that will benefit them as well.
For general surgical procedures such as hernia repair, cholecystectomy, or endoscopy, there are generally no exclusions.
Vadim Gritsus, M.D. is an in-network provider with Aetna, Cigna, Horizon, Oxford, Medicare, AmeriHealth, Amerigroup, Horizon NJ Health, United Healthcare, HealthNet and many other insurance plans.
Dr. Gritsus participates in New Jersey Medicaid plans such as Horizon NJ Health and Amerigroup.
After the first consultation has been performed, Dr. Gritsus documents all pertinent medical information in the patient’s chart. Our surgical coordinator, JoAnn, then submits a letter of pre-determination to your insurance carrier to verify that benefits are available for this procedure. This is done for each individual policy holder, as benefits can vary from plan to plan.
Some insurance companies will require patients to undergo several office visits before qualifying for Bariatric Surgery. Your visits will be set up by our office. Insurance companies will most likely authorize your procedure if you comply with their requirements. Many patients feel very frustrated that they have to "jump through the hoops" to get their weight loss surgery but we can not do anything about the rules each individual insurance company imposes. The good news is that most insurance companies will ultimately cover weight loss surgery if you meet their criteria.
In general, Medicare will cover bariatric surgery if your BMI (Body Mass Index) exceeds 35 and you have two of the following conditions: hypertension, diabetes, osteoarthritis, sleep apnea, or hypercholesterolemia. Medicare will not cover your weight loss surgery if you only have obesity, no matter how heavy you are. Medicare does not require you to go through a medically supervised weight loss program prior to the surgery. Medicare does not have a pre-certification process, which means they do not tell us in advance whether they will pay for your weight loss surgery or not. However, we generally will have an idea whether your bariatric surgery will be covered by Medicare or not based on your weight and health conditions.
If we feel that Medicare may not cover your surgery, you can still proceed with the treatment but you will have to sign an Advanced Beneficiary Notice (ABN) which will make you responsible for our fees in case Medicare declines to pay. Fortunately the fees for weight loss surgery are lower for Medicare patients and you will only be charged the amount Medicare would have paid us.
Horizon NJ Health
Horizon NJ Health is a Medicaid plan which covers weight loss surgery. Dr. Gritsus participates in Horizon NJ Health for weight loss surgery only, not general surgery. Horizon NJ Health will require that you come to our office once a month for 3 months to participate in a medically supervised weight loss program before your surgery. You will also have to see a nutritionist and psychologist as well as get a letter from your primary care physician which states that weight loss surgery is recommended for you.
Amerigroup is another Medicaid plan Dr. Gritsus participates in. Dr. Gritsus participates in Amerigroup both for general and bariatric surgery. Amerigroup covers weight loss surgery and has a set of requirements patients must complete before the surgery. You will need to come to our office once a month for 6 months to participate in a medically supervised weight loss program. You will also need to see a nutritionist, psychologist, cardiologist, and pulmonologist, as well as get a letter of medical necessity from your primary care physician.
Once a response is received, which is usually within thirty (30) days for most plans, a request for precertification is then initiated. If there are specific policy requirements or criteria that your insurance carrier requires in order to render an insurance approval, we will explain each to you, usually at the end of your first consultation.
A tentative surgery date is available to you at the time of your first consultation. This date may only be finalized once the insurance approval and all medical clearance requirements are met. If an insurance carrier requires longer than thirty (30) days to process, or if any medical requirements cannot be met within that time, your tentative date for surgery may need to change to a later date in order to provide you with the most thorough evaluation prior to your surgery.
Our insurance participation list changes periodically, so it is always best to contact our office for the most up-to-date information. You can reach our staff at (973) 696-9050 during normal business hours.
You can also fill out a contact form with any questions you may have.