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Dealing With Insurance Companies A New York Perspective

Dealing With Insurance Companies A New York Perspective. Mitchell S. Roslin, MD FACS Chief of Bariatric Surgery Lenox Hill Hospital. Who is King of the Castle?. National Heart Blood and Lung Institute. Based on NIH 1991 Guidelines

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Dealing With Insurance Companies A New York Perspective

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  1. Dealing With Insurance Companies A New York Perspective Mitchell S. Roslin, MD FACS Chief of Bariatric Surgery Lenox Hill Hospital

  2. Who is King of the Castle?

  3. National Heart Blood and Lung Institute • Based on NIH 1991 Guidelines • Bariatric Surgery for carefully selected patients with BMI > 40 or >35 with co-morbidity • No precise definition what carefully selected means • Based on late 1980’s data

  4. Center for Medicare Services • Bariatric Surgery for all medicare patients 2006 • BMI>35 with co-morbidity • Only in Centers of Excellence • No standardized requirement for length or type of dietary counseling • No standardized requirement for mental health evaluation

  5. The Policies of Major Insurers • “There are two reasons that people do things, the reason they say, and the real reason” • Current system has little difference between patient that has no significant impact from their obesity, and one who is severely limited.

  6. Major Causes for Denial • Exclusion for coverage • Absence of medical necessity as defined by absence of six month dietary history • Documentation of BMI >40 for two years • Active participation in weight loss program that includes dietary counseling, physical activity and regular weights, for six consecutive months in the last two years supervised by physician

  7. What is a Physician Supervised Diet? • No clear opinion about best diet • Doctors can write RX and operate • No long term evidence • Really a barrier • Difficult for young patients to document what they weighed for two years

  8. Read The Medical Policy • No medical evidence for their own conclusions • Dietary counseling only causes drop outs • Highlight articles that show pre op weight loss is possible and suggests that it provides better data, makes access easier and predicts patient benefit.

  9. A lot of …. • They do not ask for weight loss • No evidence for dietary counseling • Why do we need to ration care? • If lose weight fast with vlcd then no six month requirement? • About documentation, not reality

  10. Why are we rationing bariatric surgery? • Good weight losers lose weight • Does not mean others do not benefit. • Society has not placed value on obesity surgery • Expect to see high deductable and limit on coverage • Expect increase in exclusions • Long run we need to place bariatric surgery into the treatment of entities that are already treated.

  11. Are All Obese People Candidates Surgery? • Do all patients with gallstones have cholecystectomies? • Do all patients with GERD have fundoplication? • Do all patients with joint disease get replacement?

  12. Evidence Based Medicine • Evidence based medicine is based on the public perception and the lobby associated. • Joint Disease • Cardiac Disease • Cancer Therapy

  13. Absence of Uniform Obesity Agenda • Clear vision in other areas • NAAFA Acceptance of obesity • Prevention of obesity • Treatment of obesity • To win we need to treatment of diabetes, sleep apnea etc

  14. Who Makes the Rules? • State legislature and insurance board • Not insurance companies • Evidence based medicine, not editorial • Organized appeals in states where allowed • Understand difference between contract states and standard of care • Use guideline statements and other literature

  15. Beating The Barriers • No evidence for dietary counseling • No evidence that BMI has to be >40 for two years • Appeal, appeal, appeal • Patients and doctors decide what refractive to non operative therapy means

  16. Civil Disobedience • Appeal all cases denied for reasons not based on evidence based medicine • Basis has to be CMS and NHLBI standards despite there limitations • Create cost center for insurance companies • Solicit union support and highlight the prejudicial nature of these barriers • Lower level employees and hourly wage earners most effected

  17. Need to Prepare for Change • Fee for service is going to be replaced by at risk system • Currently best business model is to do as many cases as possible, in lowest risk that can get reimbursement, with lowest tort risk, as fast as possible • Replaced by model where accountable care organization is at risk

  18. We Need to Create the Future • Studies in diabetes in patients that meet metrics for GLP analogue or insulin • Those with BMI > 35 prior to joint surgery • Studies with sleep apnea with pre and post ahi • Get away from cures everything, to specific pathways that represent standard of care.

  19. Playing to Win!

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