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Ashutosh Kaul, MD FASMBS
Chair


Dana Telem, MD FASMBS
Co-Chair


Rami Lutfi, MD FASMBS
Executive Council Liaison

Members

Matthew Brengman, MD FASMBS, Past Chair
Yijun Chen, MD
Ann Couch, RN CPC CBN
Todd Foreman, MD FASMBS
Ben Kocaj, MBA

Peter C. LePort, MD FASMBS
Walter Lindstrom Jr., Esq
Mario Morales, MD
Alexander Onopchenko, MD
Jaime Ponce, MD FASMBS
Don Jay Selzer, MD

Matthew Drake Spann, MD MMHC FASMBS
Al Swope II
Nova Szoka, MD
Mary Lou Walen
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.

Committee Goals

Short-Term

1) Supervised program for mandatory weight loss holds – come up with reasonable plan like Kaiser’s model using structured curriculum for patients; leverage with MBSAQIP
2) Develop probationary program for centers who are terminated by Blue Cross based on SAR data; a compromise, period of reassessment
3) Communicate with State Chapters and Access to Care Committees to identify local & national insurance concerns with respect to insurance issues that affect access to care with policy plan changes and other restrictions affecting bariatric surgery; current and ongoing issues include:
a. Medicaid and private insurance bundled payment proposals
b. Blue Cross, United Healthcare, and other insurances nationwide 3, 6, 9 and 12-month medically supervised preoperative weight management
c. 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
d. Regional discrepancies regarding access to care and Medicare guidelines secondary to apparent "crosswalk" issues as they arise
e. Insurance policy changes – maintain communication between insurance carriers’ Medical Directors and ASMBS State Chapter Presidents
4) “How to Survive a RAC Audit” checklist – develop a resource to educate members regarding RAC (Recovery Audit Programs): How to understand the audit process, how documentation affects outcome of an audit – draft submitted for online publication, will implement an online version
5) Work with EC on necessity and timing of any new code generation proposal for intragastric balloon placement; currently in the early forms of implementing this project

Mid-Term

1) Coordinate with Program Committee on updating insurance coding educational courses at ObesityWeek 2018
2) 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

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 and expand the utilization of the insurance committee to ASMBS State Chapters, Access, Membership and their staff, i.e., continue communication process with State Chapters and Access on local and national Insurance issues
5) 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:
a. Implementation of a step by step algorithm designed to assist Members in understanding the Medicare Recovery Audit Program
b. Outline the process from start to finish of the Medicare Recovery Audit Program
c. Assist Members in improving Medicare documentation and demonstration of having met criteria prior to performing bariatric procedures
6) Assist the Access to Care Committee in 1. designing a study to evaluate discriminatory insurance benefit design in bariatric surgery, and 2. negotiations between ASMBS and major carriers to modify overly restrictive plan language in current benefit language
7) Maintain and Update the Re-Operative Tool Kit as needed
8) Regularly evaluate and update the CPT and ICD-10 Codes for Bariatric Surgery for the website; develop communication/alerts to inform members about new codes
9) Respond to member inquiries via insurance@asmbs.org “hotline” regarding insurance issues; update Insurance FAQs and online information for the website
10) Continue Process for BPD-DS CPT code in conjunction with ACS and SAGES
11) Respond to initiatives and requests for information by CMS

Specific Projects that Achieve Goals and Objectives

1) Access to Care Chair and Co-Chair added to committee; Insurance Co-Chair added to Access to Care Committee
2) Draft RAC audit checklist and submitted to EC; need to complete development of a web-based toolkit resource
3) Review of CMS changes affecting membership and the associated impact on access to care
4) Developing course content with Program Committee for an insurance coding educational course for ObesityWeek 2018
5) Frequent and timely responses to insurance inquiries via the coding hotline – committee discusses and responds to approximately five member inquiries per month

2018 Completed Projects

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