Reimbursement

1. Reimbursement Nutr 564: Summer 2005

2. Objectives • Identify the components of reimbursement • Describe the barriers • Identify resources for MNT reimbursement

3. Terms • Medigap policy – a privately purchased individual or group health insurance policy designed to supplement Medicare coverage • Medicare + Choice Medicare-covered benefits that are provided by managed care plans, e.g., HMOs, PPOs, etc, instead of the traditional Medicare program. May offer additional benefits, e.g., prescription drug benefits

4. Terms • Participating Provider A physician or practitioner who signs a participation agreement/contract to accept assignment on all claims submitted to Medicare

5. Terms • False Claim Is a claim for payment for services or supplies that were not provided specifically as presented or for which the provider is otherwise not entitled to payment • A service or a supply that was never provided • A service for a diagnosis code other than the true diagnosis code in order to obtain reimbursement for service which would otherwise not be eligible • A claim for a higher level of service • A claim for a service that was provided by an unlicensed/credentialed individual

6. Reimbursement • Details about this topic • The Third Party System • 1st party = the patient • 2nd party = the provider • 3rd party = the insurer who manages the payment

7. Reimbursement • Billing systems to connect the service to the compensation • Standards • Who are qualified professionals to provide the service? RD Credential Continuing Education Regulatory oversight - Dept of Licensing

8. Reimbursement • Billing systems to connect the service to the compensation • Insurers recognize the standards Example: CAM process

9. Reimbursement • Billing systems to connect the service to the compensation • Documentation system - INPUT Identifies the type of service provided Nutrition Counseling Identifies the scope of the intervention Initial Assessment Follow-up Identifies the duration 15 min intervals

10. Reimbursement • Outpatient Billing - Codes • Universal Bill 1992 • UB-92 Form • Standardized bill used in most facilities for services billed to third party payers • Requires two types of code numbers to be included on the bill • ICD codes • Revenue codes Urbanski P: 2001

11. Reimbursement • ICD codes International Classification of Diseases Diagnosis codes ICD - 9 CM Codes • HCFA (CMA) provides updates and training • Contains 5 numbers • first 3 are general disease system • 4th and 5th specific details on disease system, age, severity, etc. Urbanski P: 2001

12. Reimbursement • ICD codes Example 250 codes for diabetes Physician sets the diagnosis Urbanski P: 2001

13. Reimbursement • Billing systems to connect the service to the compensation • Documentation system - Authorization Documentation of nutrition risk * Diagnosis * Age * Guidelines

14. Reimbursement Nutrition Support Client not able to take 50% of estimated nutritional needs Calorie Count or Nutrition Intake Assess Physician confirmation Updated to revised periodically

15. Reimbursement • Billing systems to connect the service to the compensation • Documentation system - Submission ICD codes

16. Reimbursement • Resources • American Dietetic Association • Web site • Annual Meeting - workshops • Dietetic Practice Groups • Managers in Clinical Care • Consultants in Dietetics • Dietetics List Serves • Note: Specific discussion of fee rates is illegal. Equates to price fixing. • Networking with local practitioners

17. Reimbursement • Medicaid is very specific for the states. Cannot compare between states.

18. Reimbursement • Barriers • Insurance Policies • Medicaid policies for coverage • Private insurers’ practices • Should be the same as Medicare or Medicaid • Changing regulations • Details of submitting a claim • ICD codes • Lack of systematic feedback / QA

19. Reimbursement • Professional Activities • Support MNT Legislation • Keep informed • Communicate to your representatives

20. Reimbursement • Involve your clients • Ask about reimbursement experience • Do they know if they got compensated? • What has worked? • Share this information with other clients • Warn clients if insurance may not cover a service

21. CMS: Center for Medicare & Medicaid • MNT • Ruling issued 11/1/01 • Regulation took effect 1/1/02 • CMS issues a “National Converge Determination” • Frequency of treatment • Duration of treatment • Relationship of MNT to other services • Reimbursement rates

22. CMS and Reimbursement • Requires credential • RD as defined by CDR • State licensure or certification • Must be licensed or certified in every state of practice • Must “Enroll” as a Medicare provider

23. Reimbursement • CPT Codes Common Procedural Coding system which defines actual procedure or service that the healthcare professional performed Level I Level II Level II Urbanski P: 2001

24. Reimbursement • New CPT Codes for MNT 97802 = MNT; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes. 97803 = Re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97804 = group (2 or more individual(s)), each 30 minutes. Urbanski P: 2001

25. Reimbursement • Relative Values Units (RVU) per 15 minute increment • Set at .46 RVUs per 15 min segment for 97802 and 97803 • Set at .18 RVUs per 30 min segment for 97804

26. Reimbursement • Provider Number • Each RD should have a provider number. • Forms • From 1-3 forms to complete depending on: • practice setting • employment relationship • The RD’s local carrier can assist in this process See http://www.hcfa.gov/Medicare/enrollment/contacts Urbanski P: 2001

27. CMS and ‘Opting Out’ Why A client with an eligible service need Medicare Provider Opt Out

28. CMS and ‘Opting Out’ Medicare provider Pro • May be required by employer • Two-year opt-out period Con • Coverage at set reimbursement rate which is very low • Paperwork • Legally required to follow Medicare guidelines including • update bulletins

29. CMS and ‘Opting Out’ Opt-out • Better reimbursement