Had a patient with BMI of 90

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  • ctooch99
    ctooch99 Posts: 459 Member
    food is definitely an addiction.. there are days i wish i was addicted to drugs or alcohol. no one every tells them "just switch to lite beer and have it three times a day between walks" or " get better quality crack and do less of it"

    I get what you're saying... But trust me, you don't wish you were addicted to drugs or alcohol. Food addiction is no doubt hard to deal with, but drug and alcohol is equally harmful. (Coming from a recovering addict...just be mindful of your words)

    ^^^ THIS ^^^ - had a relative found dead in car from heroin OD. Drug addiction is something you do NOT want in your life - trust me - I would rather help a living relative lose weight any day then ID the body of a 30 year old relative who died from drugs...
  • cramernh
    cramernh Posts: 3,335 Member
    Im a Certified Medical Reimbursement Specialist in medical billing and coding. Out of my job, I review cases of patients who are opting for anything within the weight-loss category: RD visits, Bariatric MD visits, Bariatric Surgical procedures, etc.

    Im the one who will get a Case Manager from the pt's insurance on the phone and hold (often times a good 90 min chat) a discussion on learning about the pt's insurance benefits, what it will cover, wont cover, what the medical criteria is of said insurance plan in order for the pt to be considered approved for surgical status. Even make sure we have the referrals in place for pt's to see an RD/MD.

    The process is extremely involved - its not a simple call with some of the insurance plans out there because of the extreme documentation that is often required is said-pt is trying to find out if they can get bariatric-related surgery.

    There are some plans where its cut-and-dry meaning yes or no. Other plans could potentially have those benefits but have strict documentation guidelines to adhere to. Then there are the rare plans where a simple pre-certification/prior auth can be done and POOF, you have coverage - and trust me.. its rare! These plans are all how the Employers made their decision on what benefit package they wanted to go with. Or worse... Self-funded plans where the employer TOTALLY decided on what gets covered and what doesnt.

    For those that require a case manager for something as simple as RD visits, I am often shocked that you would need to compile medical necessity for the insurance to declare additional visits are needed BEFORE the patient even sets foot in the office with an RD for the first appointment. Thats rediculous in my mind but I see this all too often. And, you bet your *kitten* I fight tooth and nail for my patients to get the coverage for RD's!!!!! Especially Behavioral Health for pts with Eating Disorders... Im very aggressive with that as well!

    Surgery-capable is a 'unique' process. Every insurance, again is different. Criteria to meet is always different. And when a physician sends me the honkin' huge manilla envelope with records to review and determine if the patient has met the insurance criteria for surgery, do you have any idea how horrible it is to analyze the records before the call to the insurance is made, and after analysis, the records dont meet medical criteria to be even considered????? Its horrible. The hoops people jump through for anything insurance-related really.

    Ill compile a list of issues with the documentation (most of the time its 18 months worth of documentation, labs, tests, consultation notes,etc) and send it back to the physician indicating the patient doesnt qualify. I cant call on the insurance knowing the documentation doesnt support the surgery. I can call them to determine if they have any benefits whatsoever, and whether or not I can file a request for Exception of Service Coverage review.

    BUT - if the pt wishes to proceed, I call the insurance back, connect with the case manager and give them my analysis report, copy of the documentation and a signed-consent form that the pt is willing to be responsible for any costs the insurance plan wont cover. And those patients are required to pay up front before the surgery can happen: surgeon, assistive surgeon where applicable, facility, anesthesia.
  • LittleNicci
    LittleNicci Posts: 284 Member
    Need to be careful discussing your cases on here....I have stories but the HIPAA police scare the hell out of me.

    she didn't mention names, or even a diagnosis. I am certified in HIPPA. she is fine.

    Agreed! Well out of HIPAA range

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