Kids Left Behind: Obesity Officially a Disease, But Will Insurers Pay for Visits?


Dr. Stephen J. Pont is a general pediatrician and medical director for the Texas Center for the Prevention and Treatment of Childhood Obesity, Dell Children’s Medical Center‘s tertiary care pediatric weight management center. The Center seeks to empower families to lead healthy, happy lives through addressing four key pillars, clinical, education, advocacy and research (CLEAR), over four levels of impact: individual/family, community/city, state and national. He is a widely known expert on childhood obesity, having recently been interviewed by the Reuters international news service and on FOX 7 Austin’s “Good Day Austin” morning show.

Dr. Pont also is chair of theAmerican Academy of Pediatrics’ (AAP’s) Section on Obesity Executive Committee. In the October 2013 issue of AAP News, he notes that obesity is now officially considered a disease, but insurers are not yet paying for treatment.

By Stephen J. Pont, M.D., M.P.H., FAAP

With support from the Academy, the American Medical Association (AMA) recently reclassified obesity from a condition to a disease.

Most pediatricians, however, practice in areas where Medicaid and private insurers do not recognize and pay for outpatient office visits solely to address a child’s weight.

Therefore, physicians and other health professionals are limited in what they can do within the walls of their clinics to prevent the worsening of overweight and obesity and the comorbidities that will follow.

Whether you agree with the official classification or not, this is another positive sign of the growing public and institutional awareness that more work and resources are needed to address the childhood obesity epidemic. Hopefully, this proclamation that obesity is a disease will place further pressure on public and private insurers to recognize that obesity is a valid reason for a patient to talk with you and that a visit for overweight/obesity (e.g., ICD-9 codes 278.00, 278.01 and 278.02) should be paid for like any other visit.

Since you can bill for seeing a child who vomited last night and now is bouncing off the clinic walls with a resolving gastroenteritis, does it not make sense that you should be able to see her for being 20-50 pounds above a healthy weight before she develops a medical problem due to weight?

Or perhaps she already has a yet-to-be-diagnosed condition that might be worsening silently. Similarly, how much progress would we have made regarding clinical care for type 1 diabetes and asthma if we were not paid for the visits? No doubt, we still would have done our best to maintain and improve our patients’ health, but progress certainly would have been slower.

The AMA reclassification of obesity follows Medicare approval in November 2011 for intensive outpatient treatment for adults with obesity. Hopefully, this public statement from the AMA will move the conversation forward and re-energize state-based advocacy efforts to convince Medicaid programs and private insurance carriers to pay for outpatient office visits for childhood obesity.

Most pediatricians would agree that the obesity epidemic is a multifaceted problem that cannot be solved in their offices alone, which is why they are committed not only to clinical care but also to community advocacy. Yet, the doctor’s office is an integral part of the solution, and pediatricians have a unique and important role to play in this battle.

Following are some suggestions if you practice in an area where you are not paid to evaluate and treat patients who are at an unhealthy weight (unless they have another billable medical condition or you squeeze it into an annual well-child exam):

  • Speak with your AAP chapter’s pediatric council, which often advocates with state-based insurance plans to pay for obesity-related services.
  • Reach out to your regional private insurance carriers and Medicaid program to advocate that they recognize obesity as a billable reason for your patients to see their pediatrician.
  • Be sure that you are not missing other obesity-related diagnoses that are billable.
  • Provide medical input and leadership to community groups advocating for healthy community change.
  • Get involved in the AAP Section on Obesity, which will coordinate some of these efforts.

Medicare already has recognized obesity as a reimbursable medical condition, so it is time we make sure that kids are not left behind. We must unleash the full potential of pediatricians in the battle against childhood obesity if we are to reverse this epidemic as quickly and efficiently as possible!
©Copyright 2013 AAP News