My DH's PCP messed up the Documentation of the Medically Supv Weight Loss

My husband's insurance requires a 6 month medically supervised weight loss attempt. We knew that and he started it last November. We applied to the program at Duke. Got all of the preliminary testing done while he was doing the medically supervised diet. Scheduled his appointment to see the folks at Duke. Had all of the medical records sent over and to our amazement and disappointment, the clinical notes submitted by our PCP failed to adequately document the medically supervised weight loss attempt. UGHHHH!!!!!!! I used the same practice for my own surgery with the same insurance, so my husband reasonable expected that they knew what was required; apparently not. So here he is, doing it all over again. It looks like some of the medical testing that was done in prep for submission to insurance will have to be redone because it will age out. While the RNP that has been seeing him is sorry and wrote a letter indicating that she had been seeing my husband and what they had discussed, it doesn't matter because she didn't get the right details into the clincal notes.

If you need to have a medically supervised weight loss attempt, be sure to check with your insurer to find out exactly what they want to see in the clinical notes and then communicate that information to your health care provider. My husband's insurance requires:

vital signs, ... i.e., weight, blood pressure, etc...

discussion of weight loss program being attempted ... i.e., portion control, logging of foods, weight loss meds., high protien/low carb diet, etc...

discussion of exercise program being attempted ... i.e., walking 30 mins 3 x week, resistance training 30 mins 3 x week, etc...

discussion of behavior modificatons being attempted ... i.e., counseling sessions, attending support group meetings, working through a behavior modification program, etc...

results of attempt ... i.e., loss, maintained, gained X lbs.

I hope that if you require a documented weight loss attempt you will find out not only what the insurer wants but what is being documented at each visit so that you can avoid the disappointing and costly mistake we are dealing with now. Now we are getting a copy of each month's clinical notes. They are being submitted to our program for review so that if there is a problem it will be caught early on.

My DH is a real trooper and while he's really terribly disappointed, he's putting one foot in front of the other and working to make the best of a difficult situation. I hope that telling you of his difficulties might help someone else avoid the emotional and financial expense he is experiencing.

Barb

I just found out Friday that I ahve the same problem.. It really upset me that she did this. I even took her a copy of someone elses records so that she would know how to word everything. Not even anywhere close. Im going to a diffrent doctor for the next 6 months....all that money down the drain for nothing. Good luck on his next round maybe it will go better for both of us.

One of the things we are doing is asking for a copy of the clinical notes at each visit. If the information in the notes is not correct we will ask to have them amended on the spot. Once that is done, a copy of the notes will be submitted to the surgeon's office and we will ask the insurance specialist to review so that if there is a problem we can catch it early and not endure another 6 month wait. We have been using this primary care provider for years and will continue to do so, we'll just have to baby-sit the process.

I'm sorry to hear that you are having a similar issue. I wish you success as you move forward.

Barb

Appeal their decision...!!
After my 6 month my PCP sent in referral for a Surgeon's Consult and it was DENIED due to my doctors poor documentation every month...I was so upset.
I thought that I was going to have to do my 6 months all over again... I decided to take a chance and appeal with my own letter and within a month I had been approved... one month over 6 is well worth the try....

Dont give up !! You deserve this..

If you'd like a copy of my appeal Id be happy to share...

Best of luck,
Kellie

WOW
well that sucks!!  So, does he have to do the full 6 months over again???

Yep!

geez - I'm sorry
but you rock for coming here to warn others!!!

Hopefully, the 6 months goes quickly  - I know it likely won't but still...I hope for his sake (and yours) that it does!

Good luck to you both!

While it's disappointing, 6 months won't kill us and we'll get there.

THanks for the support.

Barb

This is sooo frustrating, believe me I know exactly how you feel...

I had this same exact problem... after doing 6 months supervised diet with my PCP, at every visit she was only documenting the everyday stuff with some notes showing interest in Gastric Bypass. I went to her every month thinking her office was doing whatever needed to be done to get an approval after my six months was up... Anyhow, at 6 months she sent referral  to the IPA for Surgeon consult and it was denied because her documentation wasn't up to their stantards...
I thought at that point I was going to have to do the 6 months all over again, I was sooooo upset... I decided to appeal it and within a month I was approved by the insurance company themselves... APPEAL!!!!  It is well worth the try.. in my case it was one month instead of the 6 months all over again....

If you'd like a copy of my appeal letter for an example.. please send me a private message.. I'd be happy to share..

Best of Luck....most of importantly... DON't GIVE UP !!! FIGHT, it is your right
Kellie

Hi Kellie,

We are still going through the process, but to be honest the insurance is a medicare replacement policy and it must adhere to the medicare guideline and that's what's called out in the medicare guidelines. While we are still working the various avenues, it is most likely that he will have to do the time.

Thanks for the support. It is truly appreciated... and congratulations on your success!

Barb