valley health - Medical Fitness Association

West Virginia Public Employee Insurance (WVPEIA)
Weight Management Program
– Insurance Reimbursed Program for Fitness
Disclosures
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Presenters have listed no financial
interest/arrangement that would be
considered a conflict of interest.
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are not the creators and have no
ownership of the WVPEIA Weight
Management program.
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have written permission from WVPEIA to
present material in this presentation.
Background
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Problem Statement:
West Virginia is among the top states in the
incidence of obesity, diabetes, hypertension,
metabolic syndrome, and heart disease.
WVPEIA members, like their fellow citizens, are
experiencing an alarming rate of these debilitating
conditions causing an escalation in the agency’s
obesity related claims.
Background
In July of 2004, PEIA initiated the Weight Management
Pilot program with a single site.
-Now a covered benefit, the service is available
at over 60 fitness facilities across West
Virginia.
Elements of this benefit include:
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nutritional counseling services provided by registered dietitians
licensed in West Virginia;
fitness services provided by exercise physiologists and personal
trainers;
access to appropriately equipped facilities; and
phone coaching by professional counselors and/or specially
trained coaches.
Background
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Effective July of 2011, PEIA amended the
program eligibility criteria to include a
broader spectrum of members who would
experience improved health via:
-nutrition services
-fitness services
-behavioral services
Background
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Effective July of 2013, PEIA enhanced the
benefit, to allow a second attempt per
lifetime.
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Effective September 1, 2013, prior
participation in the Dr. Dean Ornish
Program for Reversing Heart Disease is no
longer a barrier to participation in the PEIA
Weight Management Program.
Limitations of Coverage
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Available to WVPEIA Preferred Provider benefit
members.
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This is a twice per lifetime self-selecting, opt in
benefit with a consecutive duration of up to two
years in length.
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In cases where there has been a long absence
they start from the beginning with 12 months
remaining.
Eligibility and Access
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The WVPEIA Weight Management Program is available
to individuals who have:
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A BMI of 25 or greater;
A waist circumference of 35 inches or greater if a woman;
A 40 inches or greater if a man.
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Although WVPEIA is working to have state wide
program access, it is not yet available in every county
or every West Virginia community.
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This program is only available in the state of West
Virginia.
Members are deemed to be
ineligible if:
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They had bariatric or lap band surgery in the past
ten years. Those who have had such surgery prior
to this period will be considered on a case by case
basis.
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They have exhausted their twice per lifetime
benefit.
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Their physician or nurse practitioner does not
release them to safely participate.
Children and Adolescents
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WVPEIA recognizes the need for specialty care programs
designed to meet the needs of overweight children and their
families.
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Children who are in the 85th percentile or above, are eligible
for the program.
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WVPEIA will authorize children who may not have reached
the 85th percentile but are at risk for becoming overweight
due to any one of the following:
-trends over time
-family risk factors
-a referral from their pediatrician or family practice
physician/nurse practitioner.
Program Awareness
Participant
Interested in
Lifestyle Change
PEIA Website
WMP Marketing
Facility Marketing
Facility MAC
Word of
Mouth/Walk in
Begins Enrollment
Enrollment
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Interested PEIA members may enroll by either calling 1-866688-7493 or by using the web based enrollment application
on the PEIA website (www.peia.wv.gov).
-Phones are answered by specially trained staff at the West
Virginia University’s College of Physical Activity and Sport
Sciences (CPASS).
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If the applicant meets criteria, they are sent a packet of
materials to be completed and returned to CPASS including:
- a participant consent form
- a physician/nurse practitioner release form
- a data lab sheet.
Referral to Assessment
Email Notification to
Site Coordinator
Verification of Referral
Email Notification
Site Coordinator to
Customer Service and
Fitness Team
EP Performs
Assessment and sets
up 1 month of
Personal Training and
initial RD Appointment
Customer Service
contacts New Referral
to set up Initial
Assessment
HWF Intake Checklist
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HIPPA Form
HHQ
PEIA Expectations
Sheet
PEIA Contract
Exercise Testing
Consent
Goals Sheet
Service Schedule
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Review Database
notes
Assessment
Month 2 Nutrition
Scheduled
2-1 hr PTr Scheduled
for month 1
Nutrition Hx given
Nutrition Logs given
Email Site Coordinator
Services Offered
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The WVPEIA Weight Management Program
provides:
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Nutrition Counselling
Exercise Physiologist Consultation
Personal Training
Behavioral Health Phone Counselling
WVPEIA has developed a specific schedule of
services that is premised upon initial individualized
assessments and follow ups by the dietitian and
exercise physiologist with training services
provided by the personal trainer.
2015 Service Schedule
Member Responsibilities
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Pick one participating facility
Keep all scheduled appointments
24 hour cancellation notice
Exercise at the facility a minimum of twice per week
Cooperate with Monthly Measurements
Pay $20 monthly Copayment
Keep a food journal to be reviewed by program staff
Respect program staff and fellow participants
Notify PEIA and facility if they are unable to continue with the program
Facility Responsibilities
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AED
Comply with HIPPA
Provide professional staffing
Accept the fee schedule.
Reasonably accessible hours of operation.
Documentation on WVPEIA database
Communicate with CAMC rep for claims submission.
Communicate with staff about participant progress.
Provide Service in a sensitive, non-discriminatory manner to
all participants
Attend Annual Training
Program Expectations
Reimbursement
WVPEIA will pay only for the services rendered by the
required program professionals
 The member copayment of $20 per month shall serve as the
payment for facility access.
Coding
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Code
Description
Reimbursment
97802
Nutrition-Initial
$30.84/unit
97803
Nutrition-Follow $26.77/unit
up
S9449
Ex. Phys.
$15.00/unit
S9451
Personal
Training
$10.00/unit
Reimbursement
Reimbursement
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Database Submission
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Reviewed by Site Coordinator
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No Medical Coders needed at
Facility.
Submission is done by Exercise
Physiologists
Completion and Accuracy
Confirmation with CAMC Billing
Representative
Claim is processed
Check cut and sent to Facility
Program Challenges
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Communication
Adherence
Tracking
Unforeseen Circumstances
Budgeting
Program Evolution
Communication Challenges
Front Desk
Billing
Trainers
Program
Developer
EP
Participant
Program
Coordinator
RD
Behavioral
Counsellor
Site
Coordinator
Accounting
Communication-Database
Communication-Database
Administrative Notes
Communication-Database
Monthly Measurements
Communication-Database
Dietician Encounters
Communication-Database
Exercise Physiology Encounters
Communication-Database
Personal Training Notes
Adherence Challenges
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Independent Workouts
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Scheduling/Attendance of Appointments
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Outlook on Nutrition Changes
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Program Expectations
Adherence-Accountability
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Facility-Monthly review of Non-Compliant
participants.
- 3 step process to contact
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Customer Service, Fitness Associate, Site
Coordinator
WVU-Quarterly Review
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Minimum Qualifications being met
- EP, RD, and PTr Appointments
- Facility Attendance
- Weight loss as seen in Assessments
Program Challenges
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Tracking Appointments
- Dependent on Phase
- Dependent on Month within Phase
- Dependent on 1st or 2nd attempt
Front Desk Access to Schedule of
Services
 Personal Training Notes
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- PTr Lack of Database Access
Facility Tracking
Fitness Staff
Customer Service
Site Coordinator
Unforeseen Circumstances
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Medical Problems
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Medical Holds
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Replaced with Second Attempt
Personal Situations
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Family Problems
Moving
Job change
Budgeting
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Revenue Generator
Limited Control
Time Variance
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Reimbursement
Referrals
Limited population
- Must have PEIA Insurance
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Meet the BMI and Co-Morbidity Criteria
Benefit expires with use.
Program Evolution
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Program Changes
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Medical Holds
Copayment Amounts
Service Schedule
Second Attempt
Billing/Reimbursement
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Database Changes
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Data Entry
Pulling Biometric Data
Staffing Changes
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CPASS
HWF Case Study
Initial Behavioral Health Evaluation
HWF Case Study
Monthly Measurements
2014 WV State Outcomes
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Data was collected throughout the 2014 Plan
Year via:
- participant surveys
- monthly participant measurements
reported by facilities conducting the program.
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During the 2014 Plan Year 1632 people were
active in the PEIA Weight Management
Program.
2014 WV State Outcomes
Enrollment. Total enrollment increased in 2014. At the close of
the Plan Year, 2,460 applications had been processed, leading to
1401 active participants.
Program completion. On the other side of enrollment, 289
participants completed their 24 months of the benefit this plan year.
We have seen an increase in completion this year, likely due to
broadened eligibility requirements two years ago (reducing BMI
requirement to 25).
2014 WV State Outcomes
Medication changes. In each of the 6, 12 and 18 month
evaluation surveys collected during the Plan Year, participants
self-report whether they have experienced a reduction in
prescription medications in the past 6 months.
2014 WV State Outcomes
Bariatric Surgery Aversion. Evaluation surveys collect
information about participants that may be considering bariatric
surgery. Across all evaluation surveys collected during the plan
year (6, 12 and 18 month) 66% of respondents reported that
they were considering bariatric surgery but are now no longer
considering it.
2014 WV State Outcomes
Physical Activity. According to surveys collected this Plan
Year, 69% self-report that they are meeting the CDC physical
activity guidelines.
 54% report attending the facility at least three times per
week
 32% of respondents exercise at home or work at least three
times per week
 Only 13% of the respondents do not exercise outside of their
facility
Total weight lost. 13,011 pounds lost by program
participants.
2014 WV State Outcomes
Participant Satisfaction . Participants are asked to rate their
satisfaction with the WMP on a one to six scale, with one as the
lowest, and six as the highest. Over 90% of respondents report
being at least “satisfied” with the program across the 6, 12,
and 18 month surveys.
Questions?
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For further information on WVPEIA you can
go to:
http://www.peia.wv.gov/healthinformation/health_and_wellness_programs/
Pages/weight_management_program.aspx.a
spx
https://healthperformance.wordpress.com
Contact Information
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Kristy Harvey 304-822-7255,
[email protected]
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Jeff Jeran 540-536-3086,
[email protected]