The Medicaid Maze – Patient Assistance with Bariatric Surgery

July 18, 2014

Since 1998, when Eric Klein founded ObesityHelp.com, one of his missions has been to help people wanting to have bariatric surgery as a treatment for life-threatening obesity. Since the start, Eric has wanted to bridge the gap between support, education, and the process of having weight loss surgery. Through community peer support, a network of professionals, and the ObesityHelp Patient Assistance program, he's been able to see his mission become a reality.

What Is Patient Placement?

The ObesityHelp Patient Placement Team receives multiple telephone calls, emails, and messages every day from OH members and non-members alike requesting help to find a bariatric surgeon.

For anyone wanting weight loss surgery, researching surgeons is imperative. Whether covered by insurance, self-pay, wanting to obtain health-care loan funding, Medicare, or Medicaid, the ObesityHelp Patient Placement Team helps conduct the research of bariatric surgeons and presents information on each of the surgeons for review by the pre-operative patient.

Many factors go into the research of surgeons:

Years of experience in bariatrics
How much of their practice is bariatrics
Types & variety of weight loss surgery procedures performed
Number of bariatric surgeries performed
If the surgeon is Board Certified
Memberships in professional bariatric associations, such as ASMBS membership
Specialized training, certificates, and diplomas
Publication and/or research in the field of bariatrics

Additional factors to consider:

Does the hospital have equipment and facilities for larger patients?
Does the hospital have a dedicated bariatric program where the nurses and dieticians are accustomed to taking care of bariatric patients?
Has the facility or practice been designated as a Bariatric Surgery Center of Excellence?
How will you cover expenses of surgery-insurance, paying yourself, Medicaid, or Medicare?
Is there a Support Group that meets regularly?
Is there an Informational Seminar available to attend?
What is the after-care program like? How is their long term follow up?
What have other patients experienced? Read peer feedback, testimonials, look at before & after photos, read message board posts, stop by support group meetings, and talk to other patients.

Many of the requests we receive come from people covered by Medicaid. Medicaid is a health insurance program for individuals, families, and people with disabilities who cannot afford health care costs. Navigating the Medicaid process can be quite challenging. Patients often have insufficient access to health care providers, lack of coordination, and continuity of care, and the system itself is overburdened which negatively impacts Medicaid participants wanting to obtain information and benefits. When people call the Patient Placement team for help, many are frustrated and even more are upset as they fear they won’t be able to receive the care they need and want.

The Reality of Medicaid for Bariatric Surgery Patients

For anyone covered by Medicaid, patient placement assistance is especially important. Due to the requirements of Medicaid to obtain bariatric surgery, which can vary from state to state, the process can be overwhelming. Medicaid has strict criteria that must be met to qualify for weight loss surgery plus a limited number of surgeons that accept Medicaid to cover weight loss surgery. One of the biggest challenges the ObesityHelp Patient Placement Team faces is the limited number of surgeons and doctors that accept Medicaid. The top states that we receive a higher volume of help requests to locate a surgeon that accepts Medicaid are Illinois, Florida, Texas, Louisiana, California, and Ohio, there is an especially high need by participants to locate a physician or surgeon that accepts Medicaid.

Since January 1, 2014, ObesityHelp.com received 908 requests for assistance from Medicaid participants.

More and more Medicaid offices are overburdened and unable to provide the information in a helpful manner. It is becoming a common procedure to call the Medicaid office and request the list of bariatric surgeons that accept Medicaid. The problem with this is that usually, these lists can be as many as 100-200 doctors and surgeons of all specialties, depending on the state. The frustration sets in when they are told to call each one to determine if they accept Medicaid but when they also find out that the list is not exclusive to bariatric surgeons, that it is all doctors in the entire state!

I’ll never forget the day we had a prospective patient call due to overwhelming from a list that she received from Medicaid. She received a list of over 100 surgeons that were for all different specialties and was told to call them to find a surgeon. She felt overwhelmed to begin with but knew that she needed bariatric surgery for her health, so she began placing calls to the numbers. Call after call, she was told the office wasn’t a bariatric surgeon. Feeling discouraged, she turned to her PCP for advisement, her physician referred her to ObesityHelp. We are still in the process of assisting her to find a surgeon.

The most concerning part to me is that this was just one call. We’ve started to see a rise in calls exactly like this one. Cathy · ObesityHelp Member Services

Another limitation of insureds is the overall process of Medicaid. It is confusing and a maze of requirements (that vary by state) that can be difficult to navigate. Satisfying the medical necessity documentation along with other requirements can prove challenging in some cases. There are times when an insured will find a surgeon that accepts Medicaid but by the time they get all of their documentation and requirements ready, the surgeon may no longer be accepting Medicaid by the time their surgery date comes along. This can be a very devastating and painstaking process.

Unfortunately for the people that ask for our help to have weight loss surgery, the news isn't optimistic. The data from the U.S. Centers for Medicare and Medicaid Services reports that participation in Medicaid is rising in nearly all 50 states. Even though some states are expected to expand their Medicaid programs after 2014, an additional 8.8 million people are expected to enroll in the program by 2016. Medicaid spending is expected to grow by 7.9% on average in 2015 and 2016. After 2016, Medicaid spending growth is expected to be approximately 6.6% per year on average. The number of surgeons that will accept Medicaid will not meet the need.

Sometimes getting information from Medicaid was challenging but I had more time than I had money, so pursuing coverage for my WLS through Medicaid was my only option at the time, and had I not invested that time in myself I would not be here today.

It's been 11 years since Medicaid covered my surgery, after surgery I no longer need blood pressure medication, a CPAP machine and haven't been hospitalized for cellulitis since 2004. Beyond the health changes, I also moved on to my 1st professional job, began advocating for others, and am now working towards a Masters in Health Law. Persistence is key!Sarah · born2lbfat

The Reality of Medicaid for the Surgeon’s Office

One of the areas of concern for surgeons to accept Medicaid is that the rates of reimbursement to the surgeons are very low. In addition, billing Medicaid can be a complex process that requires a large amount of staff time to complete and submit. It also takes a considerable period of time for the surgeon to receive the reimbursement.

Some states handle their Medicaid process better than others, but generally speaking, this is the reality for bariatric surgeons and Medicaid participants. An unfortunate situation for both surgeons and Medicaid participants alike. Surgeons are frustrated with the process because they want to provide this important surgery, but in many cases, are not able to due to the ever-rising costs of practicing medicine and performing surgery.

In New Jersey, where I practice, the reimbursement from Medicaid is simply too low for anyone in private practice to accept these patients. The very few surgeons who do accept these patients are generally employed by hospitals so they don’t have the overhead of running an office.

The lack of access to bariatric surgery is doubly tragic as obesity in our country is more common among patients of lower socioeconomic status and many of these patients are covered by the Medicaid system. So the population most in need of these services cannot access the care they need because of the poor reimbursement provided by the Medicaid system. Dr. Michael Bilof · Garden State Bariatrics and Wellness Center]

I was honored to have been selected to assist in the crafting of the Medicaid guidelines for Bariatric Surgery in Colorado in 2008. At that time, we were able to add the sleeve gastrectomy as a benefit for our Medicaid patients, whereas Medicare did not begin to cover the procedure until several years later. While my practice does share in some of the frustrations for MCR and MCD patients, such as the additional hoops through which patients must jump, lower compliance rates than in commercial and self-pay patients, lower reimbursement, and longer time to reimbursement (60 days up to 1 year for payment!) I am thrilled to be able to provide Bariatric services for this underserved patient population.

What frustrates me the most is that, under the Affordable Care Act, at least in Colorado, Bariatric Surgery is not a covered benefit at all. Our government has purportedly expanded the access of the population to health care, yet not to bariatric surgery—a life-saving, quality of life-improving, co-morbidity-curing, safe treatment for morbid obesity. In addition to improving access to care, I challenge our government, and our patients, to work toward adding Bariatric benefits to the Affordable Care Act. That way we can truly make a public health impact. Dr. Matthew Metz · Bariatric & Aesthetic Surgery Associates

Despite the challenges with Medicaid, ObesityHelp is dedicated to help with the education, empowerment, and support of all individuals affected by obesity. Our Patient Placement Team is committed to helping people through the process as best as we can. For each person that has life-saving weight loss surgery, it is one less person that suffers from obesity. To reach our Patient Placement Team, you can reach them by email.