Like too many Americans, I’m officially obese (currently 212lbs on a 5’10” frame and happily dropping). Like many Americans, I hate being obese. I want to be a healthy weight and with the happy arrival of my son, I am more motivated than ever to get in shape and be a good role model. I grew up always a little on the heavy side and then ballooned up to 220 after college and that’s not a life I want for him.
I try to go the doctor every year for a physical. With the move and everything going on, I’d been slacking a bit, but my wife scheduled us up for a couple physicals and away I went. As I expected, we did the standard stuff (weight, BP, heart rate, etc) and my Doctor and I had The Talk about my weight. It’s the same chat I’ve been having with various doctors over the years, eat less, exercise more, yadda yadda yadda. I’m happy to say, since that visit, I’ve lost 10 pounds, starting exercising regularly and I’m on my way.
Fast-forward a few months. A bill arrives in the mail from my Doctor for a couple hundred bucks, claiming that my office visit wasn’t covered, nor was any of the blood work that followed. Needless to say, I was rather surprised since I’ve been getting yearly physicals for quite a while and I have never had to pay anything more than my co-pay. Long calls ensue back and forth to the Doctor’s billing department and my health insurance provider, and after much deliberation, I finally find out that I’m being denied because the office visit was classified as a sick visit with a diagnosis of Obese (99203 / 278.00 are the codes for anyone who cares).
That’s right, I’m being denied coverage because I’m obese. No bones about it.
Apparently there’s a common contract exclusion in play. Any claims with a diagnosis of obese (code 278.00) are denied by the exclusion. If the visit had been billed as a routine physical, it would have been totally covered.
But, I thought I went in for a routine physical? As far as I know, that’s what I got. The visit was no different from any other Doctor’s office visit I’ve ever had, so what gives? According to the Doctor’s office, the mere fact that we talked about my weight changed the classification from routine physical to sick visit for obesity. I pointed out that that’s not what I went in for, but they say they’ve “escalated it to the compliance department” and “checked the doctor’s notes for the visit” and everything is as it should be. Also, to change the codes back is “to falsify the record” and that by saying that I was in for a physical is tantamount to saying the Doctor is lying. I think it’s just fixing their mistake, but what do I know. At this point, they’re intractable and we’re just going to take our business elsewhere.
The thing I don’t understand is what am I supposed to do going forward? My weight is dropping, but what if I’m still obese when I should be going for my next visit? Do I refuse to talk to the doctor about it? Don’t weigh me? Not go at all? I have no idea when the appointment turned from routine physical into OMG-FATTY in the eyes of the Doctor’s office, so I have no idea when to say “no thanks, I don’t want that done.” Is every visit from here on out a sick visit for obesity? Some might think this is great motivation to lose weight, but hey man, I need a physical just like everybody else. I shouldn’t be denied basic coverage just because I’m over; if anything, I would think they’d want me in there more often to help me back to health.
What have I learned? Health insurance is incomprehensibly complicated, but they still expect the patient to be responsible for knowing what’s covered and what’s not. Personally I think that’s a lot to expect of a service most people use a few times a year. The insurance company expects you to interrupt the Doctor in the course of your evaluation to make sure that whatever it is they’re doing is covered. If the Doctor wants to run tests, even seemingly “routine” tests, you have to ask what tests and find out if they’re covered. If the Doctor wants to talk to you about an issue you’re having, it’s probably a good idea to find out if talking about that issue is covered, especially if it’s obesity. Finally, if you’re obese, find out if your insurance has an obesity exclusion in the contract and if they do, be sure your Doctor knows about it. Otherwise, it could cost you a fair bit of dough.
I’m not entirely sure what to do next.