Medicare and WLS

[Guest guest]

Frequently asked questions about Medicare's new rules regarding

obesity surgery and why the rules are causing some cancellations.

(Click here for a PDF version of Frequently asked questions about

Medicare's new rules regarding obesity surgery and why the rules are

causing some cancellations.)

On February 21, 2006, Medicare, the federal program that provides

health coverage for the elderly and disabled, announced and

immediately implemented new rules for the coverage of obesity

surgery. The FAQ's are based on the new rules as currently

implemented.

What do the rules say?

The new rule, adopted after nearly one year of review, states that

Medicare will cover open and laparoscopic gastric bypass,

laparoscopic adjustable gastric banding (the LAP-BAND SYSTEM) and

open and laparoscopic biliopancreatic diversion with duodenal switch

as long as the procedure is performed at a Center of Excellence as

designated either by the American Society for Bariatric Surgery

(ASBS) or the American College of Surgeons (ACS).

Why did Medicare adopt new rules?

Under most circumstances, decisions regarding covered procedures

under Medicare are made at the local and regional level. The

challenge with obesity surgery coverage under the previous rules was

that surgery coverage and the criteria to access surgery varied

widely across the country. Under the old local rules, some states

had great access to surgery while others had little or no access.

At the request of ASBS and others, Medicare went through a national

coverage decision process to adopt rules making coverage consistent

across the country. In addition, Medicare has become more focused

in recent years on quality outcomes for Medicare beneficiaries and

it is believed that this directly contributed to the inclusion of

the Center of Excellence requirement.

Who does this apply to?

The new rule applies only to Medicare beneficiaries who are morbidly

obese (body mass index (BMI) of 35 or greater) with any obesity-

related condition or disease, and the patient has been previously

unsuccessful with medical treatment of obesity. There are no age

restrictions. Patients who are covered by their employer's health

plan are not affected by Medicare's new rule.

Why has this ruling caused cancellations?

Due to the immediate implementation of the rule, some surgery

practices were caught off-guard and have been forced to cancel

procedures if they have not yet received designations as a Centers

of Excellence. Medicare has informed hospitals that the rules have

been implemented immediately and that they will not pay bills

associated with the surgery for a Medicare patient unless they are

performed at a Center of Excellence.

What are my options if my surgery has been cancelled?

1. Find a Center of Excellence and contact them regarding their

criteria for surgery. A list of Centers of Excellence can be found

at www.surgicalreview.org or

www.facs.org/viewing/cqi/bscn/fullapproval.html. Keep in mind that

Medicare is a national program, so you often can travel to another

state for your procedure. The Centers for Medicare & Medicaid

Services Web site also lists the facilities that are approved

Centers of Excellence at

www.cms.hhs.gov/MedicareApprovedFacilitie/BSF/list.asp.

2. Talk to your existing surgery practice to see if they have

applied for Center of Excellence status and if they have been

advised when their application will be reviewed. With this

information, you can make the decision whether to wait for your

existing practice to receive the appropriate Center of Excellence

status or choose a new practice which is already designated as a

Center of Excellence.

What is required for a hospital to be designated as a Center of

Excellence?

To become certified as an ASBS Center of Excellence, the hospital or

institution must:

Perform at least 125 bariatric surgeries per year collectively.

The surgeon must have performed at least 125 bariatric surgeries by

him or herself over a lifetime and perform at least 50 per year.

The center must also report long-term patient outcomes and have an

on-site inspection to verify all data.

The center must have a dedicated multi-disciplinary bariatric team

that includes surgeons, nurses, medical consultants, nutritionists,

psychologists and exercise physiologists.

The center must meet a variety of other requirements detailed at

www.surgicalreview.org

Requirements from the ACS are similar. For information on ACS

requirements, visit www.facs.org.

Why is Medicare requiring Centers of Excellence status?

For a variety of reasons including:

A wide variety of data suggests that surgeon experience is an

important factor in better outcomes and reducing deaths and

complications.

Data also suggests that comprehensive programs, those with pre-op

and post-op care, also report better outcomes.

The requirement of data collection (outcomes, mortality and

complications) under the Centers of Excellence programs provides

important information for future rulings.

Medicare's acting chief medical officer, Barry Straube, MD, said, "

CMS' expanded decision draws upon the specific criteria that

facilities must meet in order to obtain certification from either

the American College of Surgeons or the American Society for

Bariatric Surgery. Utilizing these groups' expertise will ensure

that beneficiaries will receive optimal care in a manner that

provides the greatest likelihood of successful outcomes from this

important procedure. "

How many Centers of Excellence are there?

As of March 21, 2006, there are 123 in 33 states.

There isn't a Center of Excellence near my home. What can I do?

You have a couple of options. The first is to be patient. The ASBS

and ACS continually certify new surgeons/hospitals.

Your second option is to contact the closest Center of Excellence to

you. Medicare is a national program so beneficiaries often have the

option to travel out of state to receive medical care.

I thought my hospital was a Bariatric Surgery Center of Excellence.

Why isn't it on the list?

Many commercial insurance companies and others use the Center of

Excellence designation. In addition, some centers may have indicated

they have applied for Center of Excellence status, but have not

received a final review. Medicare specifically required that

surgeons/hospitals be designated as a Center of Excellence by either

the ASBS or ACS.

Do all Centers of Excellence accept Medicare?

No. You will need to contact the center directly to see if they

accept Medicare and/or have any other financial requirements.

I'm a Medicare beneficiary with surgery scheduled soon, but haven't

heard from my surgeon. What should I do?

Contact your surgeon's office to see if they are a Center of

Excellence. Remember, if you have the surgery and they are not a

Center of Excellence, you may be personally liable for the surgery

and hospital fees.

Does this ruling affect my private insurance or my state Medicaid

coverage?

No. The rules apply only to Medicare beneficiaries. It is hoped that

the rules will encourage commercial insurers and Medicaid programs

to expand their coverage in the future.

I heard media reports a few months ago about Medicare eliminating

coverage of obesity surgery for those 65 years of age and older.

Will the rules allow me to have surgery?

Yes. There are no age restrictions in the new rules.

There is a great deal of confusion on this issue. As part of the

process of adopting new rules, Medicare originally proposed limiting

surgery to those under the age of 65. This proposed rule was removed

from the final decision when the obesity surgery community provided

additional data on the safety and effectiveness of obesity surgery

in older Americans.

Do all Centers of Excellence accept patients 65 years of age or

older?

No. Individual surgeons/hospitals set their own age requirements.

You will need to contact the center directly to determine their

patient requirements.

My question wasn't answered above. Who can I talk to?

Feel free to call the OAC National Office at or e-

mail us at info@.... If we don't know the answer to

your question, we'll try to find out for you or refer you to the

appropriate agency/organization.