Navigating Prescription Drug Medical Weight Loss

Stephanie Allard, CPC, CEMA, CPA-RA, RHIT

August 23, 2024

This year, a recurring issue is continuing to pop up in the audit reviews that I am completing for clients. The issue is related to medical weight loss and what I think is a complete misunderstanding in the industry regarding how or IF the services related to the management can be billed to the insurance. You may be asking yourself why this is such an issue, as medical weight loss has been around and used for many years. This is quickly becoming problematic with the introduction of prescription medications to the weight loss journey that a provider helps a patient navigate.

For me I remember hearing of drugs such as Ozempic when the media started reporting what celebrities are doing to maintain a lower weight. This has completely rolled over into society, with the public seeing advertisements, more media reporting, and large corporations now integrating and offering weight loss drugs (sometimes even conveniently through telehealth). I have heard from multiple clients that it is getting to the point where patients are walking into the practices and requesting weight loss medications at many of the appointments.

Navigating the drugs and how that transfers to coding compliance and billing has been difficult, and I am finding that not everyone is aware that they even need to research this. To ensure compliance, you must research the drug that will be prescribed to the patient. For example, if you were to search Wegovy, you would find that it is covered for weight loss with caveats. For Wegovy to be covered, the patient must have a beginning BMI of 27 or greater with at least one weight-related condition or a BMI of 30 or higher. Now, if you were to look up the drug Wellbutrin, you would find that it is not FDA-approved for weight loss. That means that when this is prescribed to a patient for weight loss, it is given for “off-label” use.

Providers and practices are also not realizing that any services related to prescription drug management would be considered experimental/investigational and not medically necessary, just like the drug would be if not FDA approved or being used for off-label diagnoses. This means that E/M services are also not billable to insurance. This is where I have found the most variances. From my experience, the misunderstanding is coming from the fact that providers are thinking that when they see a patient it is automatically a reportable service for payer reimbursement. When the drugs are considered not medically necessary, the E/M services and other services related to that management cannot be billed to the insurance company. This means that practices must consider whether they want to set up a self-pay program to continue offering the management.

In addition to the FDA approval component, we also must look at individual payer policies. I am finding that some of the commercial payers are publishing guidelines that specifically state they will not cover prescription weight loss management regardless of FDA approval of the drugs. You also must consider the fact that when patients have an employer-based health plan, the employer can designate the types of services covered under the plan. There are many that are specifically excluding this.

Lastly, another area we need to be aware of as auditors is the fact that not all the drugs are coming in their original form from a pharmacy. Meaning that many are reverting to compounding the drugs to help with the supply, demand, and cost. A compounded drug is one that is custom-made, typically by a pharmacist or physician. It includes mixing various drug ingredients to create a medication for a patient. From a compliance perspective, you must be aware that drugs that are compounded are not FDA-approved, which again circles back to the issues above with the services/drugs being experimental, investigational, and not medically necessary.

As auditors, we need to pay attention to a lot of detail and be aware of it as it relates to code selection and overall compliance. My biggest suggestion regarding a scenario like this is to be on the lookout. We have a lot of sources and outlets for information on what is trending in the industry. Following podcasts, webinars, and people in our industry on social media platforms like LinkedIn is important. The information is at our fingertips, and seeking it out does not cost extra. When you hear of trends in the industry or if you find concerning practices in your personal audits it is imperative to speak up and start conversations between those in administration and the providers. It takes an all-inclusive team approach to ensure compliance.

About Ms. Allard:

Stephanie Allard is a Senior Compliance Specialist for DoctorsManagement. She is a multispecialty auditor with proficiency in more than 40 specialties including, but not limited, to orthopedics, cardiology, vascular, neurology, general surgery, OB/GYN, PM&R, and PT/OT. In addition to performing external audit reviews, Stephanie provides feedback and education to help clients implement practices and strategies that will reduce risk in the future. She also performs forensic auditing that includes focused reviews to be used in court cases.