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E-Articles - Thinking About Gastric Bypass Surgery? Your Health Insurance Probably Requires Preauthorization
Gastric bypass surgery is expensive, so most patients considering this procedure will look to their health insurance policy to cover at least part of the cost. Some insurance policies will not cover any obesity-related treatments, but
According to USFDA, a combination product is one composed of any combination of a drug and device; biological product and device; drug and biological product
those that will pay for weight loss surgery almost always require preauthorization.
This means that your insurance company will probably ask for medical records, a treatment plan, and perhaps a letter from your primary doctor and su
This means that your insurance company will probably ask for medical records, a treatment plan, and perhaps a letter from your primary doctor and su
; or drug, device, and biological product and fixed dose combination would include two or more combinations of drug.
Examples of combination products may in
Examples of combination products may in
geon to show that you meet their criteria for benefits. Your doctor may be required to show that you have attempted weight loss in the past through other, less dangerous methods, and have failed.
If you have not already read your ins
If you have not already read your ins
lude drug-coated devices, drugs packaged with delivery devices in medical kits, and drugs and devices packaged separately but intended to be used together.
urance company’s medical policy on gastric bypass surgery, you should do so before you ask your doctor to request pre-authorization. Your doctor’s staff may already have a copy of the medical policy, but if they don’t, it is always he
here is enormous increase in the number of combination products entering the market in the recent years. Combination products have proven advantages but fixe
pful if you provide this to them. If it isn't available on your insurance company’s website, they should be mail you a copy if you ask for it.
Your doctor and surgeon may have a financial stake in helping you get insurance benefits,
Your doctor and surgeon may have a financial stake in helping you get insurance benefits,
d dose combinations are still in the process of convincing regulatory authority on their advantages over the single ingredient formulations.
Combination pro
Combination pro
but the responsibility for finding the funds for your surgery is primarily on your shoulders. You should do everything you can to make the process easier for your doctor’s staff.
The specific medical policy concerning weight loss sur
The specific medical policy concerning weight loss sur
ucts have become life saving products for the pharmaceutical companies who doesn’t have many innovative molecules in their product pipeline and have been inc
ery is a separate document from your benefit policy - it is a document that lays down the rules for coverage for this specific procedure. Your insurance company has a medical policy for most major medical treatments and diagnoses, and
easingly used in the product life cycle management. Even the companies having product patents are trying to extend their product life cycle through the combi
the medical policy often includes the company’s criteria for "medical necessity."
One thing that often confuses patients is the clause found in many health insurance contracts defining the term "medically necessary." People naturall
One thing that often confuses patients is the clause found in many health insurance contracts defining the term "medically necessary." People naturall
nation products and maximize the revenues. But the companies involved in this practice are overlooking that they are burdening the patients both economically
assume that if their doctor says a procedure is needed, the insurance company will accept this as true. However, their definition of "medically necessary" may be different from your doctor's.
This doesn't necessarily mean that the p
This doesn't necessarily mean that the p
and physically. They need to rightly judge the benefits of the combination products and they have to even look at the risks involved when combining the produ
rocedure isn't needed for your health and well-being - it simply means that your health insurance company doesn't have to pay for the surgery.
That's why you want to read the insurance company's contract and medical policy carefully
That's why you want to read the insurance company's contract and medical policy carefully
ts. Some of the combination products were well accepted by physicians while others suffered. Companies involved in development of combination products are fi
efore making any financial decisions about your treatment.
If your insurance company requires preauthorization and you go ahead with treatment without going through the preauthorization process, the surgical costs will probably not b
If your insurance company requires preauthorization and you go ahead with treatment without going through the preauthorization process, the surgical costs will probably not b
ding difficulty in defining their combination products and facing various challenges from selecting a combination to marketing it.
Following aspects would a
Following aspects would a
covered. This could be a very expensive mistake, and it can easily be avoided.
When the insurance carrier receives the pre-authorization request, their medical staff will go over the material provided by your doctor and decide if th
When the insurance carrier receives the pre-authorization request, their medical staff will go over the material provided by your doctor and decide if th
dd to the challenges in developing combination products:
Which markets to tap where the combination products can do fairly well?
Which combination prod
Which markets to tap where the combination products can do fairly well?
Which combination prod
e criteria listed in their medical policy have been met.
Your doctor's opinion about your need for gastric bypass surgery will need to be backed up by real facts and chart notes. A letter from your doctor that basically states “becau
Your doctor's opinion about your need for gastric bypass surgery will need to be backed up by real facts and chart notes. A letter from your doctor that basically states “becau
cts are meaningful and rational?
Which therapeutic categories to select?
Which Combinations can address unmet needs of the patients?
Do combin
Which therapeutic categories to select?
Which Combinations can address unmet needs of the patients?
Do combin
e I said so” is not going to impress your insurance company, although a surprising number of doctors send one in, anyway.
If you do not meet the insurance company’s criteria for benefits, you may want to carefully reconsider your dec
If you do not meet the insurance company’s criteria for benefits, you may want to carefully reconsider your dec
tions increase the patient compliance?
What would be the developing cost?
How to tackle the risks encountered during combination product developmen
What would be the developing cost?
How to tackle the risks encountered during combination product developmen
ision to have the surgery. The surgery is not without risks, and should not be undertaken without very strong facts showing that it’s needed. If it is needed, your doctor should be able to say why in a way that is acceptable to other
t?
As combination products don't fit into the traditional categories of drugs, medical devices, or biological products, the USFDA is in the process of devel
As combination products don't fit into the traditional categories of drugs, medical devices, or biological products, the USFDA is in the process of devel
edically-trained professionals.
If your request for preauthorization is turned down, you may be able to appeal the decision if:
- Your policy covers bariatric surgery,
- You qualify under the medical policy’s guidelines, and
-Your
If your request for preauthorization is turned down, you may be able to appeal the decision if:
- Your policy covers bariatric surgery,
- You qualify under the medical policy’s guidelines, and
-Your
ping new procedures for reviewing their safety, efficacy and quality.
Professional from academic institutions, pharmaceutical industries, health care indust
Professional from academic institutions, pharmaceutical industries, health care indust
doctor has provided all the documentation that was requested,
The appeal process, if any, will be carefully outlined in your benefit handbook, and you must pay special attention to the amount of time you're given to appeal, and what
The appeal process, if any, will be carefully outlined in your benefit handbook, and you must pay special attention to the amount of time you're given to appeal, and what
y and representatives from various regulatory agencies are working out to design the regulatory requirements for manufacture and sale of combination products
forms you may need to get the process started.
Remember that even if you have a right to appeal, you will need additional evidence not previously provided to the insurance carrier, unless the previous decision was clearly made in err
Remember that even if you have a right to appeal, you will need additional evidence not previously provided to the insurance carrier, unless the previous decision was clearly made in err
.
As there is an increasing trend of the combination products companies manufacturing such products should be able to tackle the problems involved in the de
As there is an increasing trend of the combination products companies manufacturing such products should be able to tackle the problems involved in the de
or. And there is no guarantee that the previous decision will be overturned.
Insurance law varies in every state, and every insurance contract is different. Be sure to seek legal advice from someone familiar with your state's insuran
Insurance law varies in every state, and every insurance contract is different. Be sure to seek legal advice from someone familiar with your state's insuran
elopment. They need to be wiser in analyzing the market trends and the regulatory requirements.
Companies that provide selfless information through particip
Companies that provide selfless information through particip
e laws if you are not sure about your benefits and rights under your policy. A clear understanding of your benefit contract will give you the best chance of receiving all the benefits that your health insurance premiums are paying for
tion in industry events and feedback to regulatory authorities would be able to face the challenges and will be successful in developing combination products
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