Wednesday, January 29, 2014

Water Cooler Talk: Insurance Issues

From Thegreenhed.com

You probably have the same area in your building.  The area of the practice, the physical place, where the scuttlebutt gets discussed, where the issues of the day are reviewed and debated by those in the know. Those impromptu forums are always informative, sometimes emotional, and a good place and time to catch up on what's the latest theme or situation, and what to look out for so it doesn't happen again.

In my experience, sometimes these spontaneous get-togethers at the 'water cooler' better help to define and describe a new issue, and allow us to get a head start on it before it becomes a more perplexing isituation in the all too near future.  Usually those meetings are more efficient than a formal meeting might be, on the topic,  that would need to take place if the water cooler talk couldn't diagnose and treat the issue at hand.

Our water cooler is in the break room.  It's the very place I speak of for our practice.

The latest issue?  Insurance issues.  Here's a new twist on the recurring theme of moving the goal posts, in so far as insurance coverage of Bariatric Surgery for 'qualifying' patients.

Long gone are the simpler days of the recommendation of the NIH, that surgery should be covered for patients that have a BMI over 40, or a patient over 35 with comorbidities.

Then came the Medicare (CMS) standard a number of years ago that surgery could oly be performed and reimbursed at CMS "Accredited Centers of Excellence", which was somewhat recently overturned.

On a similar note, as far as a change from what is expected, certain insurances will not approve a patient who has a BMI in the range of 35-39.9 without a significant comorbidity.  Most are OK with OSA, HTN on at least one medicines, DM 2, and sometimes dyslipidemia on meds.

It can get very tricky though, as the indications have more stringent recently in which HTN is described as "controlled"if normalized on one or two or more meds.  We had a recent patient who was declined for surgery due to the fact that the Pulmonary note described the patient's newly diagnosed OSA (usually an absolute indication for surgery) as "mild" and the settings on the Cpap were "low.  Not covered by this insurance plan.

What's next? controlled DM2 on high doses of basal insulin, or a pump, but a glycohemoglobin under a certain range,  therefore "controlled" (even with their grossly overweight and contributory body habitus), and "not approved"?

Other tidbits of insurance coverage in our days at the office include Medicare's requirements that essentially any comorbidity can qualify a person starting at BMI 35, but weight alone does not.  So, when we get a patient referred to us by their primary, and their weight is say 350, and BMI of 62.... If they have no associated medical condition (although not very likely) that they come to us with, or a related malady we can acutely diagnose upon their visit to us, that insurance will not approve their surgery. Sounds unlikely to happen, but it does happen to us from time to time, especially in the younger patient with a significant weight but not much in the way of associated medical conditions...so far.

And a common conundrum we often visit from week to week: Revisions.

These days they mostly have to do with converting a Band to a different procedure, due to failed weight loss, or actual issues with their Bands (Dysphagia, pain, increased GERD, gastric prolapse). One insurance company in particular, a regional HMO, steadfastly denies any attempt to get these approved and do surgery. They have a policy of one lifetime weight loss surgery.  End of story.

We have tried many appeals in the past, peer to peer reviews, and even patients initiating their own appeals, with little success.

It's the first thing I look at when I have a patient in the office that may be interested in a revision, one who would otherwise qualify based on BMI and/or comorbidities.  Our talk requires an extra layer of disclosure, and a description of the poor likelihood of approval despite a long and lengthy process, as well as the unfortunate stance of their insurance company despite most other insurances working with us to help the patients get their surgeries completed.

I feel better now that I have vented some of those topics of discussion in the office lately, some old and some new.  Keep those in mind, or give us a call, if you ever have any related questions.

I am sure that your practice has a long history of dealing with insurance companies,  the good and the bad of it, as well as the whole 'moving the goalposts' scenario that seems to go along with this territory.

The next topic could be 'prior approvals' for medicines...... Don't get me started.


From Sophy.Ca



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