Insurance Versus Self / Cash Pay Bariatric Surgery a Preliminary Discussion

How you pay for a bariatric procedure is likely top of mind, and rightly so. While bariatric surgery does not represent an intervention for an emergency concern, we all know the physical and psychological problems that plague patients with obesity. Further, surgery is expensive, no matter how you cut it, so the ideal circumstance would be to have health insurance pay for the procedure. There are some distinct pros and cons of going through the insurance process to cover bariatric surgery, just as paying cash represents a faster but ultimately more costly way forward. Let’s dive in:

Insurance Coverage and Considerations

The insurance process can be very frustrating for a patient who has finally decided after years or even decades that bariatric surgery is the best way forward. The requirements imposed by insurance companies can be rather demanding, and on top of coverage being spotty, many patients must jump through hoops to get covered. Of course, there are the usual medical necessity requirements and proof of other weight loss efforts, a history of untreated excess weight and obesity, not to mention appropriate BMI levels and certain co-occurring diseases. However, often the most challenging of the requirements to meet, and indeed the most frustrating, is the three, six, or even 12 months of medical weight loss that many insurance companies require. While they justify this requirement by saying that patients should try everything before surgery, we all know that the average bariatric patient has done just that for years and years.

Then, once patients are pre-authorized for surgery, there’s a question of shared cost. While many assume that insurance will cover all surgery costs, this is rarely the case. Insurances have co-pays, deductibles, and coinsurance, all of which can make the patient’s financial responsibility upwards of several thousand dollars. For this reason, patients must understand their insurance policy by calling their insurance company. You can also speak to our office to understand your out-of-pocket expenses and get a good idea of costs and obligations.

The Case for Cash Pay

Paying cash for your bariatric procedure may seem like a financial burden and can be challenging. However, it’s essential that we first analyze the cash pay cost against the costs that you would pay through insurance. This significantly narrows the gap between the two in many cases, mainly because Dr. Higa has negotiated an excellent cash pay sleeve rate for his patients.

It’s also important to calculate intangibles like time frame and motivation. In the time it takes to get clearance from insurance, patients who cash pay could be anywhere up to a year into their procedure. For the most dedicated patients, this could mean having already reached some of their weight loss and disease resolution goals and saving a considerable amount of money on:

1. Medications they may no longer have to take
2. Doctor appointments that are no longer necessary
3. Procedures that can possibly be postponed or canceled and
4. Food costs they no longer have to incur

Again, while these will not cover the cost of bariatric surgery in just one year, you can add it to the positive column.

What About Weight Loss Medication?

Weight loss-specific medications like Wegovy and diabetes medications like Ozempic and Mounjaro, which are often being prescribed off-label for weight loss, have shown effectiveness in helping patients lose a significant amount of weight – clinical trials for Wegovy showed up to a 15% body weight loss just from the weekly injection. That said, not all insurances cover these drugs, which can be expensive – up to $800 per month. Further, for patients with relatively higher BMIs, those over 40, it’s unlikely that weight loss medications alone will offer them sufficient weight loss to return to the normal BMI range.

With all the hype and press surrounding weight loss medications, we encourage you to read our two articles on the topics:

• Weight loss medication – what you need to know.
• Will weight loss medications replace bariatric surgery?

Whether paying with insurance or out-of-pocket, you can speak to a bariatric practice like ours to understand your financial obligations and whether bariatric surgery is right for you. Dr. Higa works with his patients to understand their suitability for bariatric surgery, which remains the same regardless of how they pay. If you are considering cash paying for your procedure, we encourage you to watch our online seminar and contact us to schedule a consultation and learn more.

We look forward to meeting you and discussing surgical options that make the most sense for your circumstances.