reimbursement nutr 564: summer 2003. objectives n identify the components of reimbursement n...
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ReimbursementNutr 564: Summer 2003
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
Medicare + ChoiceMedicare-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 Participating Provider
A physician or practitioner who signs a participation agreement/contract to accept assignment on all claims submitted to Medicare
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
Topics of Discussion
Reimbursement
WARNING
The following information refers to a topic that is not logical.
Write it down
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
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
Reimbursement Billing systems to connect the
service to the compensation Insurers recognize the standards
Example: CAM process
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
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
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
Reimbursement ICD codes
Example
250 codes for diabetes
Physician sets the diagnosis
Urbanski P: 2001
Reimbursement Billing systems to connect the
service to the compensation Documentation system -
AuthorizationDocumentation of nutrition risk
* Diagnosis
* Age
* Guidelines
Reimbursement
Nutrition SupportClient not able to take 50% of
estimated nutritional needs
Calorie Count or Nutrition Intake Assess
Physician confirmation
Updated to revised periodically
Reimbursement Billing systems to connect the
service to the compensation Documentation system - Submission
ICD codes
Does the reimbursement take place?
Reimbursement
WARNING
Actual compensation is a
Secret of the universe
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
Reimbursement Medicaid is very specific for the
states. Cannot compare between states.
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
Reimbursement Professional Activities
Support MNT Legislation Keep informed Communicate to your
representatives
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 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: 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 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
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
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
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
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
processSee
http://www.hcfa.gov/Medicare/enrollment/contacts
Urbanski P: 2001
CMS and ‘Opting Out’
Why
A client with an eligible service need
Medicare Provider Opt Out
CMS and ‘Opting Out’
Medicare providerPro 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 Out’
Opt-out Better reimbursement