Reimbursement
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Reimbursement. Nutr 564: Summer 2005. Objectives. Identify the components of reimbursement Describe the barriers Identify resources for MNT reimbursement. Terms. Medigap policy – a privately purchased individual or group health insurance policy designed to supplement Medicare coverage

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Reimbursement

Reimbursement

Nutr 564: Summer 2005


Objectives

Objectives

  • Identify the components of reimbursement

  • Describe the barriers

  • Identify resources for MNT reimbursement


Terms

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


Terms1

Terms

  • Participating Provider

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


Terms2

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


Reimbursement

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


Reimbursement1

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


Reimbursement2

Reimbursement

  • Billing systems to connect the service to the compensation

    • Insurers recognize the standards

      Example: CAM process


Reimbursement3

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


Reimbursement4

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


Reimbursement5

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


Reimbursement6

Reimbursement

  • ICD codes

    Example

    250 codes for diabetes

    Physician sets the diagnosis

Urbanski P: 2001


Reimbursement7

Reimbursement

  • Billing systems to connect the service to the compensation

    • Documentation system - Authorization

      Documentation of nutrition risk

      * Diagnosis

      * Age

      * Guidelines


Reimbursement8

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


Reimbursement9

Reimbursement

  • Billing systems to connect the service to the compensation

    • Documentation system - Submission

      ICD codes


Reimbursement10

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


Reimbursement11

Reimbursement

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


Reimbursement12

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


Reimbursement13

Reimbursement

  • Professional Activities

    • Support MNT Legislation

    • Keep informed

    • Communicate to your representatives


Reimbursement14

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


Cms center for medicare medicaid

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


Cms and reimbursement

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


Reimbursement15

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


Reimbursement16

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


Reimbursement17

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


Reimbursement18

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


Cms and opting out

CMS and ‘Opting Out’

Why

A client with an eligible service need

Medicare Provider

Opt Out


Cms and opting out1

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


Cms and opting out2

CMS and ‘Opting Out’

Opt-out

  • Better reimbursement


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