Overcoming to Become a Provider 3 REIMBURSEMENT RELUCTANCE

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2 Learning Objectives Assess if accepting reimbursement is appropriate for business. Establish Tax ID, NPI number, and CAQH log-in to start credentialing process. Outline process for benefits verification and claim submissions. Provide resources to providers for assistance with reimbursement matters. Create solutions for time management and when services are not covered or expired for the year. 2

3 Overcoming to Become a Provider 3 REIMBURSEMENT RELUCTANCE

4 Reimbursement Rumors Too much work Only covers Diabetes and Renal Disease Poor reimbursement rates It s not worth it 4

5 Why Accept Reimbursement? Do you want your services to be accessible to more clientele? Do you want to advertise yourself and business? Do you want to become a referral source for other healthcare professionals? Do you want your time to be compensated? 5

6 Is Reimbursement Right for Me? PROS Establishes RDNs as qualified healthcare professionals FREE advertising MNT & Preventive care coverage Clients want to utilize insurance benefits before paying OOP Can guarantee repeat client visits MDs prefer referring to providers Create new counseling opportunities Fair compensation CONS Lack of training in this area Learning curve for process Time lag for credentialing Services may not be covered Lower client commitment/retention Not all rates are created equal Wait time for payment Time spent troubleshooting 6

7 MNT vs Preventive Care Services MNT = providing nutrition services that address a specific condition Diabetes, GI issues Preventive = providing nutrition services that can help delay the onset of chronic conditions Overweight/obesity, CVD risk factors, abnormal BG Obesity may either be considered MNT or Preventive check with insurance provider 7

8 Where Do I Start? Write a business plan! Meet with a lawyer and accountant to review business plan Establish your business entity (Sole Proprietor, LLC, Corporation) Set up your Employer Identification Number (EIN) Set up National Provider Identification (NPI) May need to set up Organization & Provider NPIs Obtain professional liability insurance Open business checking account Credit card reader Invest in copy machine/scanner Invest in fax machine or efax 8

9 Council for Affordable Quality Healthcare (CAQH) Uniform application for credentialing After completing application, contact one of the insurance companies where applying to become a provider This registers the RD with CAQH Receive a CAQH number Need to re-attest information quarterly Or when changes in personal/business info occur NOT ALL INSURANCE COMPANIES PARTICIPATE IN CAQH CHECK INDIVIDUAL SITES OR CAQH DATABASE 9

10 How Do I Get Credentialed? Make a list of insurance providers with whom you want to become a provider Identify popular insurance providers in your area Contact local healthcare provider offices Contact state Reimbursement Rep Contact other RDs Go to insurance website Providers Become a Provider Complete form and provide CAQH number If don t participate in CAQH, follow application process Save application confirmations Will receive or mail confirming acceptance THIS PROCESS CAN TAKE UP TO 6 MONTHS 10

11 What if Insurer Is Not Accepting New Providers? Bill patient OOP and provide Superbill for client to submit Can bill as an out-of-network provider Bill insurance company and bill client the balance Contact credentialing department monthly to find out of accepting new providers in area 11

12 I m An Insurance Provider Now What? Sign and return contracts and W9 documents Review contracts for rates and billable CPT codes Save Provider Relations contact info Obtain access to provider portal sites Eg. Navinet Verify location and contact info is correct Add your website if allowed Find out how Explanation of Benefits (EOB) will be provided Set up Electronic Funds Transfer (EFT) for direct deposit Set up Office Ally account If using EMR, update profile with provider info 12

13 Marketing Yourself as an Insurance Provider Contact local healthcare provider offices Create a referral pad or business cards that list insurances you accept Drop off to healthcare provider offices Leave around community Anywhere your target audience can be found Add accepted insurances to your personal or practice website Create account on healthcare referral sites (eg. HealthProfs) with accepted insurances listed 13

14 New Patient Inquiries What is their chief complaint? If weight loss, ask for estimated height and weight for BMI Who is their insurance company? Obtain the following info for each insurance company: Patient s Legal Name DOB Member ID Group Number Provider Services Phone Number If not primary insurance holder, obtain the holder s name and DOB Ask if client has seen a dietitian in the past year If possible, have client fax you license and insurance card or submit via EMR portal Schedule appointment, then verify benefits Ask patient to have MD fax over referral or script with diagnosis (Dx) codes 14

15 Why RDNs Should Verify Benefits Instead of Clients Want to ensure getting info for correct procedure and diagnosis codes Want a name and reference number at insurance company Provides opportunity for another point of contact with patient Offer alternative options if insurance doesn t cover HSA/FSA card Packages 15

16 Verifying Benefits Call Provider Services number Have your EIN or NPI number available Follow prompts to Eligibility & Benefits Provide name, DOB, and Member ID of patient After hearing recording of benefits, ask to speak with Representative CPT codes: (initial visit) 15 minutes = 1 unit (follow-up visit) 15 minutes = 1 unit (group visit) 30 minutes = 1 unit Dx codes: Codes specified by MD Lookup at ICD10data.com If no Dx provided, ask Z71.3 Dietary Counseling & Surveillance Ask if any Dx codes are NOT covered Confirm client has not utilized any nutrition benefits this eligibility period 16

17 Documenting Insurance Benefits Date Time Representative Is this Policy Active Benefit Period Does this patient have Nutrition Counseling/Medical Nutrition Therapy Benefits? Is this benefit limited to a specific diagnosis or co-morbidity? Is there a Physician referral needed? Is there both in-network and out-of-network benefits? How many visits per year? Is there a limit on number of units? Is there a co-pay? Is there a deductible? Notes Reference number 17

18 What if there is a Deductible to Meet? Find out total deductible and amount met to date Individual vs family Client must pay out of pocket Provide Superbill for client to submit towards deductible If close to meeting deductible, submit claim and offer refund if insurance pays 18

19 At Your Client Appointments Obtain copy of license and insurance card (front & back) Have client fill out insurance info form Their info (including DOB) Insured s info (if different) Secondary insurance info Collect co-pay Have client review and sign office and cancellation policy form Note number of visits Specify rates if insurance doesn t pay Outline client responsibility for cancelled or missed appointments Insurance DOES NOT pay for missed appointments Medical release form BEST PRACTICE! Obtain a credit card to keep on file Note appointment Start and End times 19

20 What is Billable to Insurance? YES! Face to Face in-office time Indirect calorimetry MedGem/BodyGem Confirm with insurance Insulin pump training (CDEs only) MAYBE? Educational Sessions (eg. Grocery Store Tours) individual, 30 min unit , 30 min unit , 30 min unit Non-face time NO! Charting, checking benefits, wait times, /phone followups Weight or body fat assessment Personal training sessions Telehealth is currently not billable to insurance in all 50 states. Check with your individual state plans. 20

21 Submitting Claims File as soon as possible Establish a usual and customary billing rate You must bill ALL insurance companies the same rate Eg. $35/unit = $140/hr Set a rate that is higher than what you actually intend to get paid Set up Office Ally account Call to confirm if additional forms are required If submitting via EMR, obtain training Send to address provided on card or local state mailing address 21

22 CMS 1500 Form 22

23 Office Ally 23

24 Completing 1500 Form 24

25 A Note on Diagnosis Codes It is NOT within the RDN Scope of Practice to make a medical diagnosis Must obtain referral or copy of medical records from qualified healthcare provider specifying Dx EXCEPTION! RDNs can diagnose BMI If patient is self-referred, use code Z71.3 Dietary Surveillance and Counseling 25

26 Claim Submission Status If submit electronically, check no errors in submission process Fix errors accordingly and resubmit Check provider portal for claim status Note turnaround time for different insurance providers 26

27 Final Step Review Explanation of Payment (EOP) Elect to have notifications sent Download EOP from provider portal Confirm co-pay amount May have to refund client Document amount paid to provider Save copy in patient file 27

28 What Happens If I Don t Get Paid? Call insurance company and follow prompts to Claim Status Ask to speak to Representative Have copy of EOP and verification info on hand Reference number, date, time and rep name Typical roadblocks to payment: Error on claim form May have to submit additional documentation Client has matter to address with insurance company MD needed to submit referral to insurance company May have exceeded visits allowed 28

29 What about Medicare? Only covers 3 hours per year of Type 2 Diabetes or Non-Dialysis Renal MNT Obesity MNT can only be billed under a physician NPI number RDNs receive 85% of physician rate If DO NOT want to accept Medicare, must Opt-Out on CMS website, BUT Can not re-apply to become a provider for 2 years Insurance companies give credentialing preference to Medicare providers If don t formally opt-out, legally have to refer potential patients to a Medicare provider 29

30 Credentialing & Billing for Medicare Must apply through CMS Download and mail forms to become new provider Obtain Provider Transaction Access Number (PTAN) number Needed in addition to NPI Can submit claim same way as private pay If client has secondary insurance that covers services: Need to submit claim to Medicare Wait to receive denial from Medicare Submit denial with claim to secondary 30

31 What is Fee-Splitting? This is an illegal practice Physicians (or any other type of facility) can not receive a percentage of your reimbursement in exchange for using their facility or referring you clients How to Avoid: If working in a doctor office, agree to pay rent in exchange for having 100% control of billing and clients It is OK to pay dietitians working for you a percentage of your reimbursement income or hourly rate Get all agreements in writing and have a lawyer review before signing and starting to see clients 31

32 REIMBURSEMENT RESOURCES 32

33 Academy Professional Website Sign In Eat Right PRO Practice Getting Paid 33

34 Reimbursement Reps & Communities Academy Reimbursement Specialists State Affiliate Reimbursement Reps DPG Reimbursement Reps Nutrition Entrepreneurs DPG Listserves Webinars Academy Reimbursement Online Community FREE to all Academy members 34

35 Reimbursement Reads RDN s Complete Guide to Credentialing and Billing: The Private Payer Market (FREE download for Academy Members) Coding and Billing Handbook: A Guide for Program Directors and Preceptors (FREE download for Academy Members) MNT References on Eat Right Store (FREE for Academy Members) MNT Provider monthly enewsletter from Academy Guide to Insurance and Reimbursement article in Today s Dietitian (Feb 2017 issue) Making Nutrition Your Business: Private Practice and Beyond Making Nutrition Your Business: Building a Successful Private Practice (Oct 2017) 35

36 TIME IS MONEY! Spend it Wisely 36

37 Time Management Tip #1: Create Systems! Set aside a certain time per week for insurance calls Timeframe & process for submitting claims Consider using an EMR Create a tracking system for payments Excel EMR Document amounts paid (including co-pays) Note turnaround time for payments Assess at end of year Contact insurance Provider Relations annually to discuss rate increase Ditch insurance companies that are not worth your time 37

38 Time Management Tip #2: Helpers! Dietetic Interns Medical Biller Explore local colleges with Medical Billing programs Medical Billing Services Dietitian Reimbursement Services Healthy Bytes Bookkeeper EMR 38

39 Time Management Tip #3: It s OK to Say No Don t be afraid to turn down potential new clients Identify your area(s) of specialty Identify your ideal client Make your expectations for client known Responsibilities Motivation Focusing on areas of expertise and attracting ideal clientele Increases patient satisfaction return visits Decreases work on RD end 39

40 Benefits Expired Now What? Be upfront with clients about your expectations for suggested number of visits Don t let clients milk their benefits Explain can t make progress if long gaps between visits Create programs and packages that incorporate insurance benefits Sell client in upfront for greater compliance Create packages the bridge insurance benefit period gaps Create virtual counseling programs and packages Remind clients about HSA/FSA cards 40

41 What questions can I answer? 41 MYSTERY SOLVED YOU RE READY FOR REIMBURSEMENT!

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43 CREDIT CLAIMING You must complete a brief evaluation of the program in order to obtain your certificate. The evaluation will be available for 1 year; you do not have to complete it today. 43 Credit Claiming Instructions: 1. Go to OR Log on to go to My Courses and click on the webinar title. 2. Click Take Course on the webinar description page. 3. Select Start/Resume Course on the webinar description page. Complete and submit the Evaluation. 4. Download and print your certificate.