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

Kelly,

I'm sorry to hear that you have had such a negative experience.

I have to say that our experience at Duke, while not always smooth, has been much more positive and I do not share your opinion of their program. I do agree that they have been having both communication and admistrative issues, but the issue that my husband is currently dealing with is not one of Duke's making in any way, shape or form. To the contrary, they have bent over backwards to be supportive of and accomodating of our needs and working to support the requirements specifically outlined by Medicare. It is in no way their fault that Medicare has the requirements that they have or that our PCP did not effectively document the medically supervised weight loss visits to the level of detail required to support Medicare's requirements. I cannot comment on your cir****tance or experience, except to say that I'm so very sorry that your experience has left such a sour taste in your mouth regarding their program and WLS as a whole.

I wish you only health and continued success as you work towards a healtier life.

All the best,

Barb

Barb, I know you and your DH are very upset over this setback.  But, it's just a setback that can overcome.  I sure hope the RNP has learned something from this experience.

Thanks for your post which I have forwarded to a friend who is just beginning the process for WLS and has an insurance requirement for a similar program. 

Tell your hubby to hang in there!  Alice

Hi Alice, Thanks for your words of comfort and support. I will surely share them with Ben. As you have said, while disappointing, we realize that in the scheme of life, this is just a bump in the road. I hope that this post does indeed help your friend as she makes her way through the process. Thanks again for your warmth and support. Barb

Barb,
I am so sorry that Ben is going through a rough time right now.  You are such a positive role model and such a strong motivator, I know you will keep his spirits up while he keeps trying. Just tell him to never give up! 
((((HUGS)))) to you both!
Lisa

Lisa,

As always, thanks for the support and encouragement.

Wishing you all the best next week.

Barb

I'm so sorry to hear about the setback.  I'm glad your Husband is hanging in there.  My weight loss convictions have always been tenuous and a set back like that would really devastate me.

This is also making me very nervous.  I am assuming your Husband has Cigna?  Cigna requires six months of medically supervised weight loss. I went to the doctor, vitals were taken and recorded,tried Meridia but couldn't tolerate it, talked about exercise efforts and efforts I was making with my diet.  However, she did not give me a specific diet to follow?  Do you know if that was the heart of the problem?

I also thought that Duke was a Cigna center of excellence, you would think it would make it somewhat easier to get approved. 

Do you know why they won't accept a letter from the doctor stating that all of those things were discussed?

My husband's insurance in underwritten by United Healthcare Secure Horizons Medicare Complete Choice/AARP. It is what is known as a medicare advantage replacement policy, therefore must follow all medicare rules.

I also had the same coverage when I had my surgery. Like you, I tried medication. I tried Phentermine with some success. Vitals were taken, I made sure to discuss what I was doing to try to lose weight and any challenges I was having. I also made sure to discuss what I was doing for exercise and was specific about what was and wasn't working. Finally, I made sure to tell my Dr. what I was doing to institute behavioral changes ... i.e., seeing a counselor, attending support group meetings. Please know that I wasn't always successful at losing weight. That's okay, but what they want to see is that there is a multi-faceted plan in place and that you are working to lose weight. You may or may not be successful.

It is not that Ben wasn't following a prescribed diet, the problem stems from the fact that they PCP didn't document what the plan for diet, exercise and behavior modification were and what the results of the previous month's attempt had been. They are not so concerned with the chosen method of weight loss, as they are that there was a method chosen and exercised. Ben does not have to use a program such as Weigh****cher's or Jenny Craig, but the Dr. does need to document what is being done ... in Ben's case, portion control, high protien/low carb, logging food consumption and trying to keep his calorie count to N calories/day. Also his exercise plan to walk 5 days week, 30 min each day and attend monthly support group meetings to identify and develop new coping mechanisms. His PCP needs to document the plan of action this month and then report on the result next month ... i.e., N lbs lost/gained, weight stable ... and then the next month's plan.

You may want to ask your Dr. to provide you with a copy of your clinical notes and ask your surgeon's office to review those to ensure that they will meet the criteria set forth by Medicare. That is what we are now doing each month. We are also making sure that we get a copy early enough in the month that if it doesn't meet the criteria, we can schedule another appointment and get it done.

It is not Duke that will not accept the letter from our Dr. that states what they discussed, it is Medicare policy that dictates that the 6 month medically supervised weight loss attempt must be documented in the clinical notes for 6 consecutive months.

I imagine that Duke qualifies as a Center of Excellence (COE) for any insurer because the are an ASBS COE and recognized by the toughest insurer of all ... medicare. The fact that they are a COE does make it easier to get approved, but they will not waive criteria because they are a COE and to be honest, while it would make our life easier, I'm not quite sure that I would want them to waive criteria because it's there ultimately to protect us, not as a gate-keeping device.

It is not my intention to 'scare' anyone. I am hoping to alert some that you need to be proactive to ensure that if you are required to have a 3 or 6 month documented, supervised weight loss attempt that you find out exactly what the ensurer wants and then work with your PCP to ensure that you get the appropriate documentation.

I hope that this helps.

Barb

Barb

Wow, this is my husband's greatest fear!  He has Medicare, we got a sample from the surgeon's office of EXACTLY what was required at each visit with the PCP to document his 6 month supervised weight loss.  All the paperwork is supposed to be turned in to the surgeon on July 30th.  We pray it is all correct.  That is the day of his last 3 tests.  BTW - I didn't have to do all those things because my ins wouldn't cover me (I had no co-morb), so our daughter paid for my surgery in Mexico.  She offered to pay for her Dad's, but his insurance WILL pay, if he does it all the right way.  Plus, during one of his tests, they discovered nodules on one of his kidneys.  Not sure that would have been found had we gone to Mexico.  We are still waiting to hear what they are and what should be done about them.

I truly wish that our program provided the type of information that yours has. I'm hoping that what has been done so far will suffice as we move forward. I'll be getting a copy and providing it to the surgeon's office for their review and comment.

We'll keep your dear husband in our thoughts and prayers.

Please keep us posted on his progress ... WLS and kidneys.

Wishing you both all the best,

Barb

Best of luck to you and your husband concerning his kidney nodules. I hope they don't impede his kidney function in any way.

Kelly (who's 5 year anniversary on dialysis is coming up soon!!)