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    Ellen Roy
    Ellen Roy, MBA, CMPE

    As a practice manager, I am repeatedly asked, “how do you fix a depleted resource?” In private practice, the answer is simple: you do it yourself. Every specialty across the United States faces a decline in available physicians and administrative and clinical staff resources.

    In summer 2022, the obesity medicine provider to whom we referred patients for medical weight loss management left their practice. We referred patients to discuss medical weight loss to address several concerns including PCOS, infertility, pre-pregnancy weight optimization and risk reduction, metabolic syndrome, cardiovascular risk reduction, menopausal weight gain and joint/mobility issues. To best assist our patients, Dr. Saroj Fleming decided to begin offering oral and injectable weight loss medications to assist patients in combating obesity and improving their overall health.

    A view from both sides

    In fall 2022 we slowly staggered the enrollment of interested employees to assess barriers in implementation around insurance and workflow. The criteria to join the weight loss program was to have a body mass index (BMI) of at least 30 at the time of consultation. Each employee received a weight loss consultation with Dr. Fleming consisting of a physical exam, review of current medications, lab work, review of past weight loss medications and programs, nutrition counseling and review of exercise plans. Follow-up appointments were scheduled at one month, three months and six months.

    Patients were offered the following medication options: metformin, phentermine, Qsymia, Contrave, and GLP-1s (liraglutide, semaglutide, tirzepatide). In September 2022, Patient X elected to start tirzepatide and initiated the first injection at a BMI of 30, qualifying for a diagnosis of class 1 obesity. At the one-month follow-up, on 2.5mg of tirzepatide they had lost 15 pounds, averaging 3.75 pounds of weight loss per week. Having already met the programmatic goal of 1.5 to two pounds per week weight loss, the dosage was not increased. The three-month follow-up showed a total 29-pound weight loss, averaging about two pounds per week. The patient reported increased energy and activity levels. Six months into the program, the weight-loss goal of 40 pounds was reached and the patient showed weight stability on a maintenance dose. Patient X reported: “As a mom of two I have constantly struggled with finding balance. I’ve tried all the fad diets, and I try to work out 3 times a week. I never could shed the extra baby weight that I gained over the years. ... Six months into the program I have lost 40 pounds, and I am happy to share that I am more confident in my skin than ever before.”

    All our trial employee patients successfully lost weight on medication, but it quickly became apparent that insurance coverage for medication would be a significant hurdle. Immediately, our office medication prior authorization coordinator was brought into the weight loss program, as we learned that most health insurance plans require prior authorizations for some oral medications and most injectable GLP-1 medications. At the time, not all GLP-1 medications were approved for weight loss, resulting in an increase in prior authorization denials and an increase in appeals. Each insurance, even within the employee trial group, had its own medication formulary, causing variation in approvals and denials for the same medications with the same diagnosis. As of January 2023, the prescription formularies changed, allowing some employees to be grandfathered into medications while newer enrollees were denied medications.

    To help streamline the prior authorization and appeals process, our prior authorization coordinator created forms for each participant outlining diagnosis, last appointment date, medication, medication dosage and last refill date. We soon realized that since medication dosages may increase monthly to reach the weekly weight loss goal, the program needed a dedicated coordinator for prior authorizations, medication refills, questions and appointment scheduling. Our prior authorization coordinator was already a certified medical assistant (CMA) and accepted the position of weight loss coordinator. After consulting with our leadership team, we felt we were well positioned from an operational standpoint to take the program public.

    An unexpected demand

    In April 2023, our office officially launched the medical weight loss program. In working with our marketing department, we developed an online screening form to assess interested patients’ age, height, weight and risk factors. Once found eligible for the weight loss program via the screening tool, patients were able to contact our weight loss coordinators through email. The weight loss program was marketed only on Facebook and Instagram using targeted marketing within 25 miles of each of our two locations. While we knew that bariatric medicine was a depleted resource within the community, we did not expect to receive 50 requests for consultations in less than 24 hours. Due to the overwhelming demand for our services, we halted our targeted advertisements within a week to allow ourselves time to confirm the screening questions and schedule patients who originally requested information on the program. Upon restarting the targeted marketing campaign, we changed our ads to include a disclaimer that consultations were booked out over two months.

    Originally, the goal was to allow Dr. Fleming 40 minutes with each weight loss patient to review their history, lifestyle changes and the risks and benefits of each medication in detail. We quickly learned that each patient had many questions about medication, with most appointments stretching to more than one hour. Due to time constraints with scheduling and reimbursement, one-hour appointments were not sustainable for our office.

    We pivoted to have the weight loss coordinator send a patient a handout via email or the patient portal with descriptions of GLP-1 and oral medications, their side effects and lifestyle goals to offer patients better understanding of our weight loss program prior to arrival. Patients were also asked to complete a screening questionnaire about their history and habits. Each patient was also required to be up to date with annual preventative health exams with a physician or advanced practice provider (APP) at our practice before the weight loss consult. This allowed our providers to assess and address any baseline physical or mental health concerns of the patient outside of weight, ensure all preventative screenings were up to date, and ultimately helped prevent having to address non-weight-related concerns (e.g., irregular periods, birth control, pap screening) at the weight consults.

    Insurance reimbursement and demand changes

    Insurance submission and reimbursement for the weight loss claims was an easy transition for the provider and our billing department, as these codes are similar to current gynecologic visits. Initial weight loss consult visits were coded as established E/M codes of 99214 or 99215 based on clinical complexity. Coding for subsequent follow-up appointments are billed to insurance as 99213, which includes the follow-up on the medication, side effects and discussion regarding an increase in dosage if applicable. As each patient required an up-to-date annual examination by one of our practitioners prior to the weight loss consultation, we were also able to charge for a comprehensive preventative medicine visit (99395-99396 or 99385-99386, based on new or established patient criteria) for any out-of-date patients.

    Six months after opening the weight loss program to the public, our office stepped back to review the successes, program criteria and ongoing struggles. It was quite apparent that the prior authorizations and appeals for the GLP-1 medications were incredibly time-consuming for our staff.

    After speaking with our legal counsel, we moved forward with an annual administrative fee (AAF) of $100 for all commercial insurance patients. Our office was transparent with patients regarding our inability to guarantee that we can obtain insurance coverage for any specific medication:

    “The AAF is intended to cover services such as maintaining medical records, prior-authorization, third-party medical forms, insurance filings and applications, patient portal correspondences, etc. Please note that the AAF is a yearly, non-refundable fee. Our office does not guarantee that we can obtain a prior authorization for weight loss medications from your insurance company. We are unable to refund the AAF if your insurance company declines a prior authorization and an appeal of your desired weight loss medication. Additionally, your insurance company will not cover the annual administrative fee or any of these services.”

    Patients who did not pay the AAF within 75 days were unable to obtain weight loss medication refills. New patients to the weight loss program were asked to pay the AAF before scheduling a weight loss consultation. If the patient had the consultation and chose to not move forward with weight loss medications, the AAF would be refunded. If a medication was sent to the pharmacy and a prior authorization started, the patient would no longer be eligible for AAF reimbursement.

    The initiation of the AAF proved to benefit our program as it allowed us to reevaluate the patients within the weight loss program. As patients who opted to end participation in the program, the office was able to put more effort toward active patients.

    What our office expected to become a small clinic to assist those who were unable to obtain weight loss medications due to the lack of obesity medicine services in the area quickly bloomed to more than 250 active clinic patients. More than 225 weight loss follow-ups were billed in the past year, in addition to our scheduled office patients. In an eight-month sample of Dr. Fleming’s claims, the data showed Dr. Fleming was able to increase 99213s by 64% compared to the previous year. While her annual exams decreased by 11% during this period, she was able to compensate for that loss with a 156% increase in E/M revenue. Within the eight-month timeframe of this data, we were able to see a 4% increase in her overall charges. These coding changes were found to be a direct reflection of the weight loss program.

    We have since instituted a limit on new consults per day. APPs were also brought in, due to unexpectedly high patient demand, to ensure adequate and prompt follow-up of medications. While the program allowed us to fill a community need for our patients, it also allowed us to increase our service line offerings and increase our overall revenue with minimal overhead. Our office employed no new employees to manage the service line; instead, we opted to re-structure each employee’s current projects and realign tasks.

    Enough reason to move forward

    In review of the program with Dr. Fleming she spoke about her overall reasons for starting up the weight loss program:

    “I started offering weight loss medication to address an unmet need in our patient population and community. Many facets of OBGYN care are impacted by obesity, including increased rates of PCOS, infertility, pregnancy complications, GYN cancers, abnormal bleeding, and pelvic floor dysfunction. Additionally, the number one killer of women in the United States is heart disease, and we would be remiss as women’s health providers not to offer options to reduce cardiovascular risk as our patients pass through menopause and beyond. Our patients have been so enthusiastic to be able to receive obesity related care via their women’s health office, and it has been a rewarding experience for myself and the staff in our office.”

    Changes within the office ecosystem are always met with resistance. The startup of the weight loss program was not without its flaws. In the initial phases, employees were resistant to the changes and concerned with an increase in projects and fear of the unknown with a new specialty and medication offerings. These concerns were addressed with open communication, and feedback was taken to ensure office staff on both the clinical and administrative sides felt supported with the new offerings. Care was taken by front office staff to ensure that all weight loss questions were directed to the weight loss coordinator.

    After more than a year, the program has exceeded all expectations and continues to see an increase in reimbursement each month. Overall, we learned that the depletion of resources in your community does not always have to be a disservice to your patients: it could be an opportunity to provide new care options and increase patient visits with a new revenue stream.

    Ellen Roy

    Written By

    Ellen Roy, MBA, CMPE

    Ellen Roy, MBA, CMPE, practice administrator, Harbour Women’s Health, New Hampshire, can be reached at

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