Reimbursement Nutr 564: Summer 2003

Objectives n Identify the components of reimbursement n Describe the barriers n Identify resources for MNT reimbursement

Terms n Medigap policy – a privately purchased individual or group health insurance policy designed to supplement Medicare coverage n 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

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

Terms n 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 F A service or a supply that was never provided F 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 F A claim for a higher level of service F A claim for a service that was provided by an unlicensed/credentialed individual

Topics of Discussion Reimbursement WARNING The following information refers to a topic that is not logical. Write it down

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

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

Reimbursement u Billing systems to connect the service to the compensation F Insurers recognize the standards Example: CAM process

Reimbursement u Billing systems to connect the service to the compensation F 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

Reimbursement u Outpatient Billing - Codes F 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

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

Reimbursement u ICD codes Example 250 codes for diabetes Physician sets the diagnosis Urbanski P: 2001

Reimbursement u Billing systems to connect the service to the compensation F Documentation system - Authorization Documentation of nutrition risk * Diagnosis * Age * Guidelines

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

Reimbursement u Billing systems to connect the service to the compensation F Documentation system - Submission ICD codes

n Does the reimbursement take place? Reimbursement WARNING Actual compensation is a Secret of the universe

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

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

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

Reimbursement u Professional Activities F Support MNT Legislation F Keep informed F Communicate to your representatives

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

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

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

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

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

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

Reimbursement n Relative Values Units (RVU) per 15 minute increment u Set at.46 RVUs per 15 min segment for and u Set at.18 RVUs per 30 min segment for 97804

Reimbursement u Provider Number F Each RD should have a provider number. u Forms F From 1-3 forms to complete depending on: practice setting employment relationship F The RD’s local carrier can assist in this process See ontacts Urbanski P: 2001

CMS and ‘Opting Out’ Why A client with an eligible service need Medicare ProviderOpt Out

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

CMS and ‘Opting Out’ Opt-out u Better reimbursement