Benefit Plan Strategies

Benefit Plan Strategies

Many Payors provide incentives for minimally invasive procedures such as:

  • Eliminate out-of-pocket expense by waiving co-pays for the minimally invasive procedure.
  • 80% co-insurance for minimally invasive procedures vs. 70% co-insurance for open procedures.
  • Waive deductible, or eliminate part of the deductible, when patient chooses minimally invasive procedure.
  • Implement OPEN procedures as Out-of-Network with higher deductibles, out-of-pocket maximums and co-insurance.
  • Mandatory on-site or call-in RN dialog with each patient prior to surgery.
  • Incentivize patients to complete an online education tutorial prior to a surgery consultation or referral. And have the provider approve successful completion of the tutorial.

Bariatric benefit design recommendations

  • Ensure only eligible patients are approved for bariatric surgery: physicians have determined a medical necessity and that the patient will benefit from the procedure.
  • Require that eligible patients receive a comprehensive multidisciplinary evaluation, including a medical, nutrition, psychological and weight history assessment.
  • Require that only experienced, high-volume surgeons who demonstrate a minimal number of post-operative hospitalizations and mortality rate are approved to conduct the procedure, preferably at a Bariatric Center of Excellence.57

Employers should also examine plan design features related to bariatric surgery in the areas of:

  • Provider qualifications
  • Facility certification
  • Member support
  • Prior authorization
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