Monday, April 25, 2016

How the USPSTF Is Helping the Treatment of Obesity

The United States Preventive Services Task Force (USPSTF) has been in the news recently because of its controversial recommendations on mammograms and prostate screening for cancer.  As the name indicates, the task force focuses on preventive care. And the Affordable Care Act (ACA) has given the task force the "sole authority to determine which preventive procedures must be paid for by insurers." Indeed, this is why insurers are now required to cover certain aspects of obesity treatment.

The ACA was put in place in September of 2010. The act put teeth in the preventive guidelines that were already established by the USPSTF. The USPSTF grades preventive measures, giving grades of A, B, C, D or I. For those preventive measures given a grade of A or B, the ACA requires that insurers reimburse healthcare providers for performing the services without requesting any copay or coinsurance. The idea being that certain preventive services will reduce healthcare costs in the long run.

Since obesity is such a big health problem, the task force graded counseling for diet and exercise as B. So, by virtue of the ACA directive, obesity counseling must be covered by insurers. This was good news for both the provider and the patient. The provider could get paid for his or her efforts, and the obese patient could avoid, perhaps, some of the comorbidities associated with obesity at a lower costs.

However, as stated above, the USPSTF has made controversial rulings on mammograms and prostate screening. And these rulings have caused some to believe that while the task force should be able to look at empirical evidence regarding health, the task force should not be involved in insurer payment. It is felt that "what insurance should pay for ought to be the job of a separate entity that could weigh "broader public health and social impacts."

Limiting the USPSTF's ability to influence insurers might not be a bad idea, but it could put a crimp in the nascent obesity payment activity now in place. And that could be a problem for obese patients and weight loss providers.

Friday, April 22, 2016

Reimbursement for Obesity Treatment

In the past, one of the problems with adding obesity medicine to a primary care practice was reimbursement for the obesity services from third party payers. Of course, getting paid is less of a problem for those obesity medicine physicians who use a cash-based payment system. However, for those providers desiring insurance reimbursement, there was no way to get paid via insurance for obesity treatment until the passage of the Affordable Care Act (ACA) in 2010.

Before the ACA, to get paid, practitioners had to code for conditions associated with obesity rather than obesity, even though many of the conditions were thought to be caused by obesity. So the providers would treat and code for type 2 diabetes, sleep apnea, heart disease and other obesity related ailments. With the passage of ACA, CPT and ICD codes were designated that can be used by providers to get third party reimbursement for obesity treatment. And ACA directs insurance companies to pay for the obesity treatment (in the form of obesity counseling) without requiring any copay or coinsurance from the covered patients.

CPT codes that can be used for obesity counseling are codes 99401-99404 for commercial payers and G0447 for Medicare. The obesity ICD-9 codes are V85.30-V85.39, V85.41-V85.45 (Of course, appropriate ICD-10 codes should now be used).

Further, Medicare specified the healthcare providers that Medicare will reimburse for obesity treatment. The providers must be in one of the following specialties: General Practice, Family Practice, Internal Medicine, Obstetrics/Gynecology, Pediatric Medicine or Geriatric Medicine. A Nurse Practitioner, Certified Clinical Nurse Specialist or Physician Assistant can also do the counseling. While this kind of provider specificity was not indicated for commercial insurers, most commercial insurers will likely use guidelines similar to the Medicare guidelines for reimbursement.

Finally, according to a speaker at the American Society of Bariatric Physicians (ASBP) conference in 2015, no guidance is given as to what obesity counseling should entail. The speaker, however, alluded to a suggestion that the USPSTF (United States Preventative Services Task Force) recommendations be followed. These recommendations are as follows:  Employ "behavioral management activities, such as setting weight-loss goals, improving diet or nutrition and increasing physical activity, addressing barriers to change, self-monitoring, [and] strategizing how to maintain lifestyle changes."

At any rate, it is now possible for obesity medicine providers to get reimbursed for obesity treatment. So, it is now more feasible than in the past for a primary care physician to include obesity treatment in his or her primary care practice, if he or she so desires. 

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