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Coding, Billing, and Reimbursement Barriers to Obesity Care

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Summary

Assessing barriers that impact patient access to obesity care and educating stakeholders on how to mitigate them can advance solutions toward improving care.

Administrative barriers are not the only factors impacting how persons with obesity access healthcare services but assessing these barriers and educating stakeholders on how to overcome them can advance actionable solutions towards improving care.

Obesity is a highly prevalent and serious chronic disease affecting over 42% of adults in the US. Projections suggest that nearly 50% of adults will have the disease by 2030. Environmental and genetic factors contribute to the development and persistence of this complex disease and persons with obesity are at increased risk for a host of complications.

Due to long-held social and medical misconceptions about the disease, persons with obesity consistently face clinical and non-clinical challenges in obtaining appropriate support and care. Diagnostic coding, medical billing, and reimbursement for obesity care can present complexities that may impede access to care for persons with obesity.

To further assess the level of impact, Avalere conducted a mixed-methods analysis, which included:

  • A diagnostic coding assessment across six different code-types (e.g., International Classification of Diseases, 10th Revision [ICD-10] Z-codes) to identify codes and code sets associated with diagnosis and care for persons with obesity
  • A claims-based diagnostic coding and service utilization analysis of six million claims across payer types to understand variations in obesity coding and billing
  • Expert stakeholder interviews with nine obesity medicine providers and six payers to validate the data analysis, assess insights on administrative barriers to care, and identify potential solutions
Figure 1. Five Key Diagnostic Coding and Administrative Barriers to Care for Persons with Obesity
Figure 1. Five Key Diagnostic Coding and Administrative Barriers to Care for Persons with Obesity

The results of the analysis suggest that the uptake of diagnostic coding, medical billing, and reimbursement practices for obesity-related services does not reflect incidence of obesity relative to other serious chronic diseases. These challenges ultimately impact how stakeholders view obesity as a chronic disease and consider appropriate treatment methods, as well as how patients access evidence-based obesity care. Understanding the impact of these challenges informs the need to address barriers to care for persons with obesity via targeted solutions.

Download the full white paper, “Barriers to Obesity Care.”

This research was supported by Eli Lilly. Avalere health maintained control of editorial decisions and topic selection.

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