Getting Paid for Obesity, Overweight Services

Health Plans Re-evaluating Payment Protocols

May 17, 2010 08:30 am Sheri Porter

With their extensive training and emphasis on treating the whole person, family physicians are the medical specialty of choice to help Americans live healthier lifestyles and shed some excess weight in the process. Unfortunately, insurance companies have never been keen on paying physicians to counsel or treat patients regarding weight-related topics alone -- despite the fact that since at least 1997, ICD-9 codes have existed for obesity, unspecified (278.00); morbid obesity (278.01); and overweight (278.02).

Physicians have learned the hard way, however, that the existence of a diagnosis code or a CPT procedure code in no way ensures that a payer will actually pay the physician to provide those services.

In fact, several FPs told AAFP News Now that they've learned from trial and error how to get paid for the work they do with patients on obesity, weight loss and healthy living issues. "You can't code for obesity first, or insurance companies won't cover it," notes Sasha Stiles, M.D., of Marblehead, Mass.

Jill Grimes, M.D., of Austin, Texas, says "I'm not coding it as a weight-loss visit; I'm coding for things like hypertension and hyperlipidemia."

And Frank Domino, M.D., of Worcester, Mass., says, "I just squeeze the diabetes care in around the healthy living discussion and bill for the diabetes, or if present, nonalcoholic fatty liver disease."

It may seem counterintuitive, but health plans seem reluctant to invest in prevention when it comes to achieving or maintaining a healthy weight, even though they readily acknowledge that obesity sets patients up for a host of serious health problems.

"You don't get paid as much to do prevention as you do to see a sick patient." says Steven Masley, M.D., of St. Petersburg, Fla. He adds that insurance companies seem more willing to pay for medications than for wellness measures that physicians provide.

Grimes says that in her part of the country, many plans cover seeing a dietitian, "but not if you're (just) 20 pounds overweight and healthy."

Payers Changing Protocols

Susan Pisano, vice president of communications for America's Health Insurance Plans, or AHIP, acknowledges that, traditionally, "obesity has been looked at as a risk factor rather than the primary diagnosis."

However, Pisano says, "This is an area that is changing." She notes that the prevalence of obesity is causing insurance companies to rethink their long-held payment protocols.

"There are some private plans that do pay specifically for obesity as the purpose of the office visit," says Pisano. In addition, some insurers are beginning to pay for the other services physicians provide with respect to the role obesity plays in conditions that are reimbursed.

Pisano declined to give specific numbers, but she promised that the number of health plans changing their payment polices was "more than a few," and that the number was trending upward.

Credit some of the push for more comprehensive wellness coverage to the nation's employers who have a stake in keeping their employees healthy.

Helen Darling, president of the National Business Group on Health, recently told AAFP News Now that two-thirds of the nation's Fortune 500 companies cover evidence-based preventive care, such as annual physicals, at 100 percent of cost.

Insurers Cover Bariatric Surgery

In terms of receiving insurance coverage, higher levels of obesity often trigger payment, says Cynthia Hughes, C.P.C., an AAFP coding expert. "When patients get to the point of qualifying for bariatric surgery, they've hit the golden ticket when it comes to insurance coverage," she says.

"Even Medicare has a national coverage decision allowing bariatric surgery," notes Hughes, but patients have to be morbidly obese to qualify.

Indeed, one of the nation's largest health insurance companies provided proprietary copyrighted information to its network physicians in 2009 regarding coverage for bariatric surgery. According to that insurer, bariatric surgery is indicated for obese patients with specific comorbidities such as type 2 diabetes, cardiovascular disease and life-threatening cardiopulmonary problems.

The same health plan claimed that conservative nonsurgical obesity treatments, such as low-calorie diets, exercise programs, behavorial modification regimens and pharmacologic therapy, have a 95 percent failure rate. The insurer cited a 2007 CDC document as the source of this information, but AAFP News Now was unable to locate any CDC document to confirm the statistic.

Interestingly, more than a decade ago, the validity of that 95 percent figure was called into question in an article published May 25, 1999, in The New York Times. The article, "95% Regain Lost Weight. Or Do They?(" notes that the statistic has been "quoted widely over the last four decades in Congressional hearings, diet books, research papers and seminars."

It quotes Thomas Wadden, Ph.D., a professor of psychiatry at the University of Pennsylvania in Philadelphia, who says, "That 95 percent figure has become clinical lore." He adds that there is no basis for it, "but it's part of the mythology of obesity."

His argument raises the possibility that health insurers are basing coverage decisions on faulty data.