Frequently Asked Questions
Which Duke health plans provide coverage for bariatric surgery?
The Duke Select, Blue Care and Duke Options plans all provide bariatric surgery coverage assuming the individual meets all the eligibility criteria. Bariatric surgery is not covered if you have the Duke Basic plan. You must receive services at the Duke Metabolic and Weight Loss Surgery Center sessions in reference to bariatric surgery.
How many years of service with Duke are required in order to be eligible for the bariatric surgery benefit?
The benefit will be available after the employee has five years of continuous service (as verified by the continuous service date) with Duke University or Duke University Health System. The member must meet the 5 year requirement prior to entering the evaluation stage.
What are the requirements that one has to meet to be considered for having the surgery performed?
You must meet the established precertification criteria including having participated in one of the following programs within the past 6 months:
- Pathways to Change (Live for Life); or
- Weight Watchers (weekly attendance w/ exercise log showing exercise 3x week, and at least 2 nutritionist visits for a six month period.
- Five years of continuous service at Duke;
- BMI of 40 or more (or from 35-39 with significant comorbidities that would be improved with weight loss); and
- Payment of the $2,500 copayment.
How soon can I start the 6 month weight loss program?
You must have met the 5 year eligibility requirement before you are eligible for the procedure.
What happens if I start a program with Live for Life or Weight Watchers, but don't indicate that I want the program to count towards the 6 month multidisciplinary program required for the Bariatric Surgery evaluation?
If you inform Live for Life that you want your current program to count towards the 6 month program required for Bariatric Surgery evaluation, you must still meet all of the program requirements and eligibility requirements. Completion of the program is no guarantee that your surgery will be approved.
What is the coinsurance/copay that I am responsible for the surgery itself?
You are responsible for the $2,500 copay, which must be paid-in-full at the time of the surgical procedure. This copayment applies to the surgery only. In addition, you will be responsible for the applicable deductibles, coinsurance and copayments for other services provided to you including but not limited to office visits, labs, x-rays weight loss programs prior to the surgical procedure.
Prior to my bariatric surgery and after my surgery, what is my responsibility for copays, coinsurance, etc. under my Duke health coverage plan?
There are two components to this benefit once you have met the precertification requirements and are eligible for the benefit.
The first is the "Evaluation" component which is designed to provide education for you and information for the Duke Metabolic and Weight Loss Surgery Center surgeon and will result in a decision by you and your surgeon about the appropriateness of a surgical weight loss procedure for you. You are responsible for copayments associated with the services involved in this Evaluation according to your normal benefits ($15 primary care, $45 specialists).
Subsequently, when it is determined that you are an appropriate candidate for a bariatric surgical procedure and you decide to proceed with obtaining the service, there is a "package" of services included in the definition of "bariatric surgery" which include the surgery itself, and the additional attention of the surgeons during the defined post-operative period. Your responsibility for this benefit is $2,500. The standard benefits as described in the Schedule of Benefits will apply in relation to all other services.
When do I pay the $2,500 copayment?
Payment will be requested once you meet the precertification requirements and your surgery has been approved by your health plan. The $2,500 copayment must be paid in full to the hospital at least two weeks prior to your surgery date or your surgery will be cancelled.
What if I cannot pay the $2,500 in one payment?
Please contact a Financial Care Counselor at the Metabolic Weight Loss Clinic to make other payment arrangements, i.e., installment payments or payroll deductions, to pay the $2,500 co-payment prior to surgery. Interest-free installment payments or payroll deductions can be made over a six month period prior to your surgery date.
May I have my surgery performed by the physician of my choice and the facility of my choice?
No. The surgery is covered only if performed at a Duke University Health System facility by a Duke Metabolic and Weight Loss Surgery Center surgeon and you meet the requirements of the Duke Metabolic and Weight Loss Surgery Center. The Duke Metabolic and Weight Loss Surgery Center surgeon must also request precertification from Prima Health if you are on the Duke Select plan or BCBSNC if you are on the Duke Options or Blue Care plan.
Are my dependents eligible for bariatric surgery assuming I have met my five years of continuous service as an employee with Duke?
Yes, assuming that the dependent is at least 18 years of age and meets all other eligibility requirements.
Does the Duke bariatric surgery benefit allow me to have another bariatric surgery if the first procedure does not work?
The benefit provides for one bariatric surgery procedure per lifetime.
If I had bariatric surgery under another policy prior to Duke providing benefits for bariatric surgery, am I permitted to have an additional bariatric surgery as a Duke member providing I meet all the other eligibility requirements?
In general, this is not covered.
Will any of my benefit limits such as nutritional visits be reduced by me entering the bariatric surgery program?
In general, any services you have as a component of your bariatric surgery program will not count toward your limits listed in your Schedule of Benefits. However, nutritional visits received as part of the weight loss program will count toward your benefit limits.
Are any complications due to a previous surgery for morbid obesity covered under another carrier's policy or self-pay prior to me becoming a member under Duke's health benefit plan policy covered by my Duke plan?
Complications due to surgery covered under another policy or self-pay will only be covered if a medical emergency and then only covered until you are stabilized. You can refer to the exclusion section in your health benefit plan documents.
After I have my surgery, will my health plan cover surgery to remove any excess skin?
No, any surgery or procedures for removal of excess skin will not be covered by your health benefit plan.
If I had lap-band surgery prior to January 1, 2010, will adjustments be covered under this benefit?
If the prior surgery was performed at Duke and if you have 5 years of continuous service, the adjustments may be covered only at Duke.
When lap-band adjustments are required, what is my member responsibility for payment?
Your benefits will revert back to your standard benefits in your health plan Schedule of Benefits.
Who do I call if I have a question about my bariatric surgery benefits?
For general health plan inquiries, you may call the health plan customer service number located on your health plan member ID card. For precertification, please call the number listed on your ID card.
Once I enter the pre-evaluation phase, will I automatically be eligible for the bariatric surgery?
No, the decision as to whether you will receive bariatric surgery as a covered benefit under your health plan depends on whether you meet all the pre-evaluation and evaluation requirements and you and your Duke Metabolic and Weight Loss Surgery Center surgeon agree that you should proceed with the surgery and that you are approved for the surgery.
When is my process certified?
Once the health vendor has received the precertification request from the Duke Metabolic and Weight Loss Surgery Center, they will render a decision within 3 business days, provided they have all the necessary information. If approved, The DMWLSC will be notified verbally and you will receive a written confirmation of the approval.
If I am denied, what is my appeal process?
If your request for Bariatric surgery is denied, the health vendor will notify in writing and provide the reason for the denial. The written notification will include detailed instruction on how to appeal the decision.