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.
8 replies on “The Obese Tax”
Sounds like a small claims court issue to me.
Holy sh!t dude, SERIOUSLY? Who provides your coverage?
Coverage is BCBS of Florida through my employer, service was rendered by Community Care of the Albany area.
have you requested your chart notes for the visit? If not you should do so immediately–there are timely filing restrictions! Usually if a routine physical is requested there is a separate physical form (sort of a check list) that is filled out by the physician and becomes part of your chart record. The addition of the discussion regarding the obesity issue should have been documented and the service separated from the routine physical (CPT 99396–Diagnosis Code V70.0) and billed as a sick visit (CPT 99212–Diagnosis Code 278.00) with a modifier -25 attached to the 99396. Both services can legitimately be billed together if the the doctor clearly documented both services. Bottom line, if the routine physical was started and the form is part of the chart record then the coding can be ‘corrected’ and the chart note submitted with the claim for clarification. Hope that is helpful—you do have recourse! You can request copies of your chart notes at any time and most offices will not charge you. Just to claify–if the office rebills with both services (going only by what you wrote in your post, that is how it sounds to me like they should correct the problem) you would be responsible for the 99212 charge due to the 278.00 which is a common contract exclusion (becoming ever more common!) but the charge for that portion would be significantly lower than the 99203!! Good luck—don’t give up!!
Thanks Jewelz, that’s very helpful! Notes are on their way and will hopefully be here tomorrow so I can review them. The thing I’m still not clear on is this: how in the world was I supposed to know that was going to be billed this way? I just went in for a physical and he brought up my weight at the end. From past experience, this seems like standard operating procedure and I don’t understand what “service” was rendered above and beyond the physical. He told me I was overweight and needed to lose some.
BTW, I forgot to mention that now you know that 278.00 is a common contract exclusion–tell the doctor about the exclusion at the start of any subsequent visits. Be very specific with the doctor that you are not there for that reason–state the reason for the visit is specifically a routine physical. Unless, of course, you want to be treated for obesity! I have found that most physicians do not have a treatment plan for this condition other than the standard–eat less, move more—-or they want to write a prescription (a whole different subject I won’t go into!! LOL!!) Also just FYI, I have been a medical biller for over 5 years and have rebilled successfully many times for similar situations.
It is VERY difficult to know how each physician determines the services–and a lot of times they don’t even know the options!! I spend a lot of my time reviewing chart notes to determine if all services performed are being billed. If this was a New Patient visit it should have been billed as a routine physical with 99386 for new patient, instead of 99396 (established patient) if he only mentioned the that you needed to lose weight and didn’t give any detailed advise or counseling then there isn’t even enough to bill separately–there has to be significant time spent in addition to the physical. It should have been billed with the diagnosis code of V70.0, technically the 278.00 could be a secondary code and the visit should still be paid with the as routine V70.0 as primary
holy cow. nice info jewelz.