Helmuth Billy, MD
Chair

Ashutosh Kaul, MD FASMBS
Co-Chair

Wayne English, MD FASMBS
Executive Council Liaison

Members

Matthew Brengman, MD FASMBS, Immediate Past Chair
Michael Barker, MD
Yijun Chen, MD
Ann Couch, RN
Todd Foreman, MD FASMBS
Matthew M. Hutter, MD MPH FASMBS
Gregg H. Jossart, MD
Ben Kocaj, MBA
Peter C. LePort, MD FASMBS
Walter Lindstrom Jr., Esq
Rachel L. Moore, MD FASMBS
Mario Morales, MD
Alexander Onopchenko, MD
Jaime Ponce, MD FASMBS
Beth A. Schrope, MD
Don Jay Selzer, MD
Mary Lou Walen
Kevin Wasco, MD FASMBS
Thomas White, MD FASMBS

Ad Hoc

Nicole Gier, Ethicon
Natalie Heidric, Ethicon
Chris Gallagher, Washington, D.C.

ASMBS Staff Liaison

Leslie Vinson

Mission

  • To advocate for healthcare policy that ensures patients access to high quality prevention and treatment of obesity.
  • To be a highly valued specialty society that serves the educational and professional needs of our diverse membership.

Description

The Insurance Committee bridges the gap between the details of insurance coverage and coding and the practicing surgeon. We focus on education of the surgeon and office administrative staff on the trends and changes in insurance coverage, coding and insurance access. The committee acts as a liaison between the ASMBS, insurers and CMS on the specifics of coverage for bariatric procedures. The committee seeks to identify new and commonly performed bariatric procedures and act as a champion for the development of CPT codes for effective and efficient reimbursement. Finally, the committee acts in concert with other committees of the ASMBS on acute and chronic access to care issues.

Objectives

  • Increase reimbursement for bariatric and metabolic surgery.
  • Ensure appropriate CPT Coding.
  • Provide clarity on insurance issues to members.
  • Be a resource to ASMBS State Chapters, Access and Membership and their staff.

Short-Term

  1. Insurance Course at Obesity Week-End 2016
  2. Toolkit – find out impact/feedback/data on uses; send message to members that it exists
  3. Create “How to Survive an RAC Audit” checklist
  4. Work with EC on necessity and timing of any new code generation proposal for intragastric balloon placement
  5. Regularly evaluate and update the CPT and ICD-10 Codes for Bariatric Surgery for the website
  6. Update FAQ and online information for the website
  7. Develop communication/alerts to inform members about new codes
  8. Handle Insurance Hotline emails to respond to member inquiries regarding insurance issues
  9. Create updates for dissemination to membership via connect and the web site
  10. Maintain communication with Insurance carriers’ Medical Directors, ASMBS State Chapter Presidents regarding policy changes
Specific Projects that Achieve Goals and Objectives
  1. Coordinated with Program Committee to develop faculty and curriculum for Obesity Week-End 2016 Insurance and Coding 4-hour session “Course: Insurance Issues 2016, Surviving RAC audits, ICD-10, and Reimbursement Challenges”
  2. Reviewed proposed changes in the plan benefits under Health Care Service Corp (HCSC), the parent corporation of BC/BS of IL, TX, OK, NM, and MT, and the proposed changes to coverage for band removal. Developed and submitted letter of response in conjunction with the Access to Care Committee Chair, Co-Chair and the ASMBS Texas State Chapter President regarding proposed changes in the plan benefits affecting Blue Cross and Blue Shield of Texas, Illinois, Oklahoma, New Mexico and Montana
  3. Discussed and responded to approximately 5 member inquiries via Insurance Hotline per month regarding insurance issues
  4. Determine FAQ for dissemination to membership via e-newsletter and website and continue to develop communication/alerts to inform members about new codes and updated insurance coverage changes

Mid-Term

  1. Develop a resource to educate Members regarding RAC (Recovery Audit Programs)
  2. How to understand the audit process, how documentation affects outcome of an audit; currently in Checklist form, Connect article can be submitted for publication following Obesity Week-End 2016
  3. Develop a resource for our Members that describe the direct implications on the future ICD-10 on bariatric codes, diagnosis, etc.
  4. Communicate with State Chapters and Access Committees to identify local & national insurance issues
    • Current and ongoing issues include Medicaid and private insurance Bundled payment proposals, Blue Cross and United Healthcare 6 month Medically supervised weight management, and other access to care barriers
    • Currently primary issue of concern is with respect to Aetna’s requirement for medically supervised preoperative weight management program during which there can be no net weight gain as a condition of approval for bariatric surgery in collaboration with the Access to Care Committee
    • Initiate Discussions with Blue Cross of California and United Healthcare to consider revising or eliminating mandatory six month medically supervised weight management requirement
  5. Assisting in evaluation of regional discrepancies regarding access to care and Medicare guidelines secondary to apparent “crosswalk” issues as they arise
  6. Continue to coordinate with Program Committee on updating insurance coding educational courses at ObesityWeek 2016
  7. Monitor AMA CPT or RUC issues that would involve bariatric surgery: continue to develop and pursue need for CPT Codes for bariatric issues as they arise and approach AMA CPT panel as required
Specific Projects that Achieve Goals and Objectives
  1. Completed a preliminary RAC audit checklist which is ready for submission to EC and have completed a Connect article for publication consideration following Obesity Week-End 2016 which is ready for submission
  2. Review of CMS changes affecting membership and the associated impact on access to care

Long-Term

  1. Achieve leadership on insurance issues
  2. Pursue and negotiate with major carriers a plan to implement exceptions to 6 month medically supervised weight management criteria or once in a lifetime bariatric surgery restrictions based on evidence based medicine
  3. Prepare for bariatric CPT codes review when notified
  4. Be a resource to ASMBS State Chapters, Access, Membership and their staff
  5. Expand the utilization of the insurance committee as a resource to ASMBS State Chapters, Access, Membership and their staff
  6. Develop and implement a resource guide for understanding Medicare Guidelines; assist members in improving documentation of having met Medicare guidelines prior to performing bariatric procedures:
    • Implementation of a step by step algorithm designed to assist Members in understanding the Medicare Recovery Audit Program
    • Outline the process from start to finish of the Medicare Recovery Audit Program
    • Assist Members in improving Medicare documentation and demonstration of having met criteria prior to performing bariatric procedures
  7. Assist the Access to Care Committee in designing a study to evaluate discriminatory insurance benefit design in bariatric surgery
  8. Assist the Access to Care Committee in negotiations between ASMBS and major carriers to modify overly restrictive plan language in current benefit language
  9. Continue to finalize course content with Program Committee to develop Coding and Insurance Courses for ObesityWeek 2016
  10. Maintain and Update the Re-Operative Toolkit as needed
  11. Continue coding hotline
  12. Continue communication process with State Chapters and Access on local and national Insurance issues
  13. Prepare for bariatric CPT codes review when notified
  14. Provide support to re-operative task force as needed
  15. Continue Process for BPD-DS CPT code in conjunction with ACS and SAGES
  16. Respond to initiatives and requests for information by CMS
Specific Projects that Achieve Goals and Objectives
  1. Coding and Insurance Courses for ObesityWeek 2016
  2. Frequent and timely responses to insurance inquiries via the coding hotline

2016 Completed Projects

  1. Insurance Course at Obesity Week-End 2016
  2. Coding and Insurance Courses for ObesityWeek 2016