A. What Registered Dietitian-nutritionist Services Are Reimbursable By Third Party Payers?

February 2017 Issue

Guide to Insurance and Reimbursement
By Krista Ulatowski, MPH, RDN
Today's Dietitian
Vol. nineteen, No. 2, P. 40

Today'south Dietitian provides practical steps to filing claims, coding, and getting paid.

Ask new private practice dietitians virtually i of the virtually challenging tasks they face in establishing their businesses, and they'll likely wrinkle their noses and say "insurance." Yep, getting credentialed and contracted with private practice insurance companies certainly tin be challenging, but it doesn't accept to be daunting. Navigating the reimbursement maze on behalf of clients and patients likewise tin can be tricky, but the following guide provides a roadmap to help.

Why Accept Insurance?
There are several reasons for dietitians to accept insurance instead of choosing to have clients pay out of pocket. The Affordable Intendance Act (ACA) improved access to preventive services for the general patient population. Nutrition counseling is widely covered by many insurance plans.

The emphasis on preventive services makes it possible to obtain reimbursement for services with an A or B rating by the United states of america Preventive Services Job Force. These include "good for you nutrition counseling" and "obesity screening and counseling," which were more than difficult in the past.1

Dietitians who accept insurance brand their services bachelor to clients who may be unable to beget intendance otherwise. Some dietitians, even so, opt to take self-pay clients only, citing that accepting insurance may lead to more no-shows or cancellations if clients aren't "on the claw" and paying via cash, check, or credit card.

However, dietitians who have moved from self-pay to accepting insurance ofttimes see growth in their practices. Being a provider using a variety of insurance companies increases the number of clients yous can encounter, often at no cost to clients.

Haley Goodrich, RD, LDN, owner of INSPIRD Diet Consulting, notes that accepting insurance "exponentially increases the number of people I am able to piece of work with. It makes diet health care affordable for people while withal allowing the provider to be reimbursed well."

Kelly Ahearn, MS, RDN, CDN, of Ethnic Nutritionist, says that before her recent move abroad, accepting insurance opened doors to her as well. "Doctors were more than interested in referring clients to me when they knew I accepted insurance. Patients found me directly from their insurance companies. It provided me with a chance to assist those who didn't want or have the means to pay out-of-pocket costs, and helped me to grow my practice and help more than people, then information technology was a win-win."

Setting up a private exercise to have insurance is fourth dimension-consuming and can take months to complete before yous're fix to accept insurance on behalf of patients. But resources abound: Resources for MNT reimbursement, both public and private, can exist plant at "Getting Started With Payment" on the University of Nutrition and Dietetics (the Academy) website.ii Whatsoever method(south) y'all cull for your do, knowing how to navigate the payment systems is important to provide high-quality care, abet for competitive pay for dietitians, and amend clients' access to diet counseling.

Public Insurance
In improver to cocky-pay and individual insurance, RDs can accept public or government insurance on behalf of clients in the form of Medicare and Medicaid.

Medicare
Medicare is a federal health insurance program that provides insurance for United states of america citizens aged 65 and older, as well as those younger than 65 with certain disabilities. Medicare covers individuals with diabetes (all types except prediabetes) and kidney disease (except inpatient dialysis) and for 3 years following a kidney transplant. By condign Medicare Part B providers, dietitians tin seek referrals from physicians and brand a difference in this growing and underserved population. Medicare Part B covers outpatient medical care such as medico visits, lab tests, and preventive care.

Medicare Office C provides the same benefits as Medicare Office B but through private insurance companies via Preferred Provider System plans or Health Maintenance Organization plans. Clients with Health Maintenance Organization plans may need referrals from their primary health intendance providers before visiting dietitians. Apply for enrollment with your state'south Medicare carriers past completing the CMS-855I grade at cms.gov through the Provider Enrollment, Chain and Ownership Organisation. For more information, visit the Academy's "Medicare Basics for RDNs" webpage: http://www.eatrightpro.org/resources/practice/getting-paid/getting-started-with-payment/medicare-basics.three

Medicaid
Medicaid provides health coverage to millions of low-income Americans, including eligible adults, children, significant women, the elderly, and people with disabilities. Equally dietitians, information technology's also wise to empathise Medicaid coverage, which is administered past states and thus varies state to state.

Is Medicaid coverage bachelor in New York? Does Medicaid cover obesity in California? What is the Medicaid reimbursement rate for Texas? Asking questions such as these and not knowing where to find the answers volition lead to frustration. For example, in select states, Medicaid covers telehealth, diet counseling for pregnant women who are considered at risk nutritionally, and preventive nutrition assessments for children up to age 21. Yet, in other states, Medicaid may not cover such services. For a comprehensive comparison of what states volition and will non cover, come across the George Washington University department of health policy's "Medicaid Fee-for-Service Treatment of Obesity Interventions."4

It would be ideal if everything was streamlined and efficient, simply until then dietitians should consult their Academy reimbursement representative for their state by visiting the Academy'southward Leadership Directory.5 Your country rep tin assist you ascertain whether country licensure is required, whether Medicaid is an selection for coverage in your state, and more. In improver, nutrition counseling reimbursement house Healthy Bytes has created a "Nutrition Reimbursement State Guide" with detailed information nigh reimbursement rates and answers to more common questions for all fifty states.six

What's on the Horizon?
Nutrition billing is complicated and chop-chop irresolute. Time will tell whether President Donald Trump will repeal the ACA as he alluded to during his campaign. As of this writing, there was speculation that he would go along to protect individuals with preexisting health weather from discrimination past insurers, even so he may defund sure aspects of the police such as restricting Medicaid expansion. It'due south unknown how quickly the ACA volition exist repealed; however, the Republican party'southward delay would requite regime time to develop its replacement instead of leaving millions of Americans without medical coverage. Since Dec 2016, Republicans take been suggesting a "repeal and delay," which would take three years to put into outcome.

Such limitations could impact dietitians who are advocating for Medicaid reimbursement for MNT. Susan Paredez, MS, RD, CDN, who serves as the Academy's reimbursement representative for New York, says that in her state RDs are challenged since Medicaid currently doesn't reimburse for MNT. "Governor Cuomo's initiatives to improve wellness care for Medicaid recipients presents a unique opportunity for RDNs to get involved," Paredez says. "This initiative is called the Delivery System Reform Incentive Payment [DSRIP] Plan, and its goal is to reduce unnecessary infirmary admissions and emergency department visits by Medicaid recipients. This could be a model for the hereafter of wellness intendance in this land," she says, adding that DSRIP may allocate funds for diet initiatives. Paredez too notes that in one case RDs receive licensure in the state of New York, Medicaid coverage for MNT may follow.

Getting Started
If you determine to accept insurance, what comes adjacent? There are two primary parts to getting set up with insurance: credentialing and contracting.

Credentialing
To become an in-network provider, otherwise known equally condign "credentialed" with the carriers of your choice, y'all'll need the post-obit:

• an Employer Identification Number;
• a license (if required in your state);
• a National Provider Identifier (NPI); and
• liability insurance, which is available from Mercer Consumer Professional Liability Insurance for dietitians at a discounted rate through the Academy.

In add-on, it's key to become ready as a health care provider via the Council for Affordable Quality Healthcare ProView (CAQH). The CAQH serves as a digital filing chiffonier where yous can securely store your information every bit a provider. One time you enter your basic personal information, instruction and preparation, and specialties and certifications into the CAQH portal, you tin authorize specific health plans to admission your data for credentialing. Insurance companies yous authorize will review your CAQH and send you further information.

Credentialing is no pocket-sized feat. Co-ordinate to Amy Roberts, PhD, CEO of Healthy Bytes, this process can have upwards of 20 hours to consummate the required paperwork. This is why many either approach the procedure with endless patience, or they outsource the process to a company that has countless patience.

Contracting
Contracting is the process of becoming an in-network provider with insurance companies. Information technology also establishes the policies and guidelines for filing claims for plan members. Phone call and inquire the provider services contact whether the insurance company is currently accepting new dietitians in your surface area.

The contracting turnaround time varies depending on the insurance visitor. Some companies contract quickly in every bit little every bit one calendar month, and some may have as long every bit six months.

Filing Claims 101
Once yous're credentialed and contracted with ane or more insurance companies in your state, you lot're ready to file your offset claim. Each claim filed will involve conducting an eligibility and benefits check, filing a merits, and getting paid.

Conducting an Eligibility and Benefits Cheque
An eligibility bank check is used to verify the services that your patient'due south wellness insurance covers. You lot're checking to see whether the patient's plan covers diet counseling services and whatever additional diagnosis codes. Go comfortable, as yous may be on concur for a while, simply once you reach a representative, the following are questions to enquire:

• Are at that place diagnosis restrictions? Learn whether the visit is for preventive or another nutrition-related diagnosis, and inquire which procedure codes are covered past the plan.
• Is there a deductible? A deductible has to be met earlier insurance companies will pay. It's important to know whether patients have met their deductibles, because if they have, then they'll be covered for services. If they haven't, they'll have to pay out-of-pocket until they meet their deductibles.
• Is there an out-of-pocket max? This information is the amount that the client needs to reach earlier coinsurance kicks in.
• Are there boosted copayments or coinsurance? Copayments may be required at each office visit fifty-fifty later on deductibles are met. Coinsurance is the percentage of the service that the insurance company covers. This usually applies after the deductible and out-of-pocket maximum have been met.
• Is a referral from a primary care provider required? Patients may need a grade from their primary intendance provider giving them permission to see you for specialty services.
• Is there a maximum number of visits allowed? Ask whether there are restrictions on how many visits patients can have covered by insurance in the contract year. Be sure to clarify when the contract twelvemonth starts.
• What'due south the reference number for this call? In case the claim gets denied and you need to appeal it, a reference number will help you cite the data you were told on this telephone call.

Filing a Merits
It's fourth dimension to neb the insurance carrier for your face fourth dimension with your patient.

If you opt to manage claims reimbursements on your ain, you'll need to become familiar with the Health Insurance Claim Form, or the CMS-1500 form, for claims filing. Dietitians can find the grade at the Centers for Medicare & Medicaid Services website (world wide web.cms.gov); this grade is used for both private and public insurance. RDs should ensure that during their time with clients they collect the necessary information to complete the form, eg, client contact data, appointment of birth, reason for visit (diagnoses), insurance member ID number, human relationship to insured, and signature. Post-obit a client'due south engagement, consummate the form and file it electronically through a clearinghouse, or utilise a nutrition reimbursement company such as Healthy Bytes to assist. Dietitians tin can observe a comprehensive explanation of claims filing in the Academy's RDN's Complete Guide to Credentialing and Billing: The Individual Payer Market , available online and free for Academy members at eatrightstore.org.

In that location are two key code sets used to file claims: Current Procedural Terminology (CPT) codes and diagnosis codes (ICD-10-CM). These codes inform insurance companies what client services or procedures RDs provided.

For MNT, the post-obit CPT codes are standard for private insurance, Medicare, and Medicaid and are the nigh commonly used:

• 97802: MNT, initial cess and intervention, individual, face-to-face with the patient, each 15 minutes;
• 97803: reassessment and intervention, individual, face up-to-face up with the patient, each 15 minutes; and
• 97804: grouping (two or more individuals) visit, each 30 minutes.

Diagnosis codes, on the other paw, are used to describe weather. When you lot receive a client referral from a medical provider, you must inquire for the ICD-10 diagnosis lawmaking. 1 common code is Z71.3 for "Dietary counseling and surveillance"; even so, all insurance types may not accept this code. The Academy publishes a listing of codes you're likely to use as a dietitian.7

For Medicare, first use 97802 as long equally another RD or wellness care provider didn't use it for the patient within the final iii years. Medicare covers 3 hours of MNT in the initial agenda year and 2 hours in subsequent years if patients have physician referrals. When you lot accept exhausted benefits for the calendar year and the referring doc determines there's a change in diagnosis for which dietary changes are necessary, then utilize the post-obit G codes for the remainder of the calendar yr:

• G0270: a xv-minute individual session for MNT reassessment and subsequent interventions post-obit a 2d referral in the same year for a change in diagnosis, medical condition, or handling regimen; and
• G0271: a 30-minute group session for MNT reassessment and subsequent interventions post-obit a second referral in the same year for a change in diagnosis, medical condition, or treatment regimen.

Medicaid coverage for MNT nutrition counseling related to obesity treatment varies so widely state by state that information technology's best for dietitians to check with their state reimbursement representative to ostend coverage.

Getting Paid
When dietitians choose to take insurance, they tin can even so set their billable rate, merely the insurance company volition set the reimbursement rate. Research what's considered a competitive charge per unit for your geographic location, and when possible, negotiate for a higher reimbursement level from the carrier. Mandy Enright, MS, RDN, RYT, reimbursement chair for the University'south Nutrition Entrepreneurs Dietetic Practice Grouping, suggests RDs telephone call their insurance carrier annually to discuss a reimbursement rate raise: "If you have a proficient human relationship and see a lot of clients through a particular insurance company with whom you accept been working for some time, reach out and ask for that heighten. What have you got to lose?"

Many RDs find that reimbursement levels are competitive with what they were charging self-pay clients. Information technology can take anywhere from a few days to a few weeks to receive payment from insurance companies. Payment is either made via paper cheque or direct deposit.

Rates vary widely by carrier and state for individual insurance reimbursement, but on boilerplate RDs can expect approximately $118/60 minutes nationwide, according to Healthy Bytes' data. Rates for Medicare and Medicaid reimbursement also vary state past land. For Medicare, Alaska currently has the highest initial appointment unit rate of $39.12/unit of measurement or $156.48/hour (RD nonfacility rate), while Arkansas and Missouri have the lowest initial engagement reimbursement rate at $27.80/unit or $111.20/hr.eight

Pitfalls, Mistakes, and Insider Tips
Even though yous meticulously go through all the important steps necessary to file claims for reimbursement, keep in mind there volition be times when claims are denied.

Denied Claims
If a merits is denied, call the insurance company immediately and take the following information ready: your NPI number, tax ID number, patient's proper name, appointment of birth, fellow member/client ID, and merits ID, and the service date of the denied claim. Ask virtually the status of the merits and the reason for denial.

The following are several reasons why a claim may be denied:

Typos
Perhaps a elementary error was made on the form, eg, you accidentally stated the diagnosis code as Z73.one instead of Z71.three.

How to set it: Each third-party payer has a different procedure for correcting errors. Contact the carrier to find out their preferred method or consult their website. Then refile a corrected claim.

Medicare Is the Chief Insurance
If a client's primary insurance is Medicare, the secondary insurance carrier most likely will deny the claim.

How to ready it: Send the claim directly to Medicare with a GA modifier. RDs should utilise GA modifiers when they suspect services won't be covered. Obtain a signed Advance Beneficiary Notice from the Medicare beneficiary to pecker the patient. If the reason for the denial is "exhausted benefits," obtain a new referral and utilise Grand codes. If y'all enter an ICD-10 lawmaking for which Medicare denies payment (eg, N18.9 for "chronic kidney disease, unspecified"), then the stage of kidney disease must be specified.

The Code Isn't a Billable Service
Essentially, the process or diagnosis codes (or both) aren't covered nether the patient's plan.

How to fix information technology: Unfortunately, there's no fix, but this can be avoided in the time to come by performing an eligibility cheque as described before. Asking the client sign your part policy document that includes mention of their financial responsibleness to pay you if their insurance doesn't comprehend services.

The Claim Was Practical Toward a Deductible
Technically, the claim isn't denied. The insurance company merely won't cover the customer all the same.

How to fix it: In this example, there's no fix, but an eligibility check can forestall such a surprise by determining how much of the deductible has been met to date. Request the client pay out-of-pocket.

Insurance Tips From the Pros
Sarah Koszyk, MA, RDN, founder of Family. Food. Fiesta., is no stranger to filing claims. 1 tip she offers to make claim filing run more smoothly is to write down the name of the person with whom you spoke when conducting an eligibility cheque, in addition to the date and time for your records. Brand sure you confirm the ICD-x and CPT codes you program to submit with the representative. "This mode, if the claim gets denied, y'all have proof when y'all call back to rectify," Koszyk says.

Koszyk also suggests using a full nine-digit null code for speedier reimbursement. "I've had challenges submitting claims when I didn't utilize the nine-digit zip code for billing. Before that I was using my five-digit zip code and they weren't getting approved."

Enright suggests conducting eligibility checks "in batches" rather than making a single phone call to the insurance carrier for each cheque. She amasses a few new clients each calendar week before placing the call, during which she'll inquire for verification of patients' CPT and diagnosis codes, the number of units and visits that she can bill, whether at that place are any copays or referrals needed, whether her clients have a deductible to meet, and lastly, whether there are any diagnosis codes that insurance doesn't cover. Some companies will cover an initial RD visit simply in one case in a client'southward lifetime, so make sure to check whether a patient has seen a dietitian in the past. Another carrier in her state of New Jersey will cover each RD visit only up to one hour.

"I once had a Medicare client who had already seen an RD at another facility," Enright says, "and thus a portion of my fourth dimension was not eligible for reimbursement due to terms of my client's coverage, equally he had maxed out his nutrition counseling benefits for the twelvemonth."

This is where Enright could resubmit the customer's claim using G codes. E'er ask Medicare beneficiaries whether they've seen an RD earlier coming to run across you.

Reimbursement Alternatives
Accepting insurance may non be the right choice for every individual practice. But you know what's best for your concern. The post-obit are alternatives to accepting private insurance:

• Paying out of pocket, or self-pay: Dietitians who choose not to accept insurance tin request payment from clients in the class of cash, check, or credit bill of fare.
• Packaged services: Many RDs are offering a bundle of services at a discounted cash price.
• Health savings accounts or flexible spending accounts offered past a client'due south employer as part of the client's benefits package: Dietitians are accepting money from these types of sources equally a form of payment.
• Superbills: In lieu of accepting insurance, RDs tin can encourage clients to submit claims for reimbursement on their own if they have out-of-network coverage and provide them with documentation for billing in the form of a superbill. This medical receipt should listing diagnoses and MNT codes so patients can file with their insurance for direct payment.

Y'all Don't Take to Get It Alone
If you're seeing one or two patients per week and you lot're already comfortable with coding, it may brand sense to file claims yourself. This is particularly truthful if you lot see the aforementioned types of patients all the time, such equally those with diabetes or those only with Blue Cross. It as well may brand sense to exercise your ain billing if you accept merely one insurance company and have fourth dimension to learn the coding. However, if you don't desire to become it alone, the skilful news is that you don't have to.

There are billing companies that tin can manage credentialing and contracting, and insurance reimbursement and denied claims on your behalf. Outsourcing is a pot of gilt for dietitians who either don't accept the time to manage the back-terminate paperwork involved with insurance or don't want to.

Healthy Bytes is one such company. Roberts and her squad help dietitians go fix with insurance companies and provide a full-service billing platform designed for diet counseling and so dietitians can submit claims electronically. Powered past advanced machine learning, Healthy Bytes reduces errors and speeds processing, taking dietitians only 45 seconds to file a claim. Roberts notes that her dietitian clients who get in-network providers increment their revenues by more than than 300% within the showtime year.

Function Ally'due south Practice Mate also offers costless claims submission and processing services via their software. Their software features a dashboard for tracking claims and acquirement, supporting multiple providers in a unmarried office or among multiple offices, creating superbills, and managing payments and deposits using automobile posting.

Ultimately, dietitians should look for a billing house that specializes in nutrition counseling. Vet potential billers as yous would any vendor by researching their diet experience, fee structure, and reporting capabilities. Many services tend to come with minimums, so cheque for monthly fees and make sure you take a high enough volume to justify using a biller. Billing payment software is a dainty middle ground for well-nigh practices and comes with the added bonus of existent-time reporting.

For those who accept the resources, another option is to rent an assistant to manage billing and other office responsibilities.

Consult with other dietitians who have been accepting various forms of payment to acquire more about what works best for them and why. Consider outsourcing reimbursement management if that seems similar an attractive option for yous. Residuum bodacious that experts are available; if you need a copilot to help y'all brand sense of your roadmap to reimbursement, seek one out.

— Krista Ulatowski, MPH, RDN, owner of KUcumber Nutrition Communications, creates and implements marketing, communications, social media, and public relations programs for RDs and nutrient companies. She wishes to disclose that Healthy Bytes is one of her clients. She also wishes to give thanks Ann K. Silver, MS, RDN, CDE, CDN, for her review and contributions to this article.

References
i. Health care reform and preventive services. Academy of Nutrition and Dietetics website. http://world wide web.eatrightpro.org/resource/advocacy/illness-prevention-and-handling/access-to-health-intendance/healthcare-reform-and-preventive-services. Accessed December ane, 2016.

2. Getting started with payment. Academy of Nutrition and Dietetics website. http://www.eatrightpro.org/resources/practise/getting-paid/getting-started-with-payment. Accessed December ane, 2016.

iii. Medicare basics for RDNs: condign a provider. University of Nutrition and Dietetics website.
http://www.eatrightpro.org/resource/practice/getting-paid/getting-started-with-payment/medicare-basics. Accessed December ane, 2016.

seven. ICD-ten-CM. Academy of Nutrition and Dietetics website. http://world wide web.eatrightpro.org/resource/practise/getting-paid/basics-and-bolts-of-getting-paid/icd-10-cm. Accessed December one, 2016.

viii. University of Nutrition and Dietetics. Medicare fee schedule. http://www.eatrightpro.org/~/media/eatrightpro%20files/practice/patient%20care/medical%20nutrition%20therapy/mnt/news%20and%20events/medicare-fee-schedule.ashx. Accessed December 17, 2016.