Reimbursement Pro provides practical steps to filing claims, coding, and getting paid.
Ask any new private practice dietitians what is the most challenging tasks they face, and they’ll likely wrinkle their noses and say “insurance.” Yes, getting credentialed and contracted with insurance companies certainly can be challenging, but it doesn’t have to be daunting. Navigating the reimbursement maze on behalf of clients and patients can also be tricky. This following guide provides a roadmap to help.
Why Accept Insurance?
Dietitians choose to take insurance rather than have their clients pay cash for a number of reasons. The general patient population now has better access to preventive services thanks to the Affordable Care Act (ACA). A lot of insurance plans cover nutrition counseling.
Because of the focus on preventive services, services that receive an A or B rating from the US Preventive Services Task Force can be reimbursed. These include “obesity screening and counseling” and “healthy diet counseling,” which were more challenging in the past.
Clients who might not otherwise be able to afford care can benefit from the services of dietitians who take insurance. However, some dietitians choose to only accept self-paying clients, arguing that if clients aren’t “on the hook” and pay with cash, check, or credit card, accepting insurance may result in more cancellations or no-shows.
Nonetheless, dietitians who switch from accepting insurance to self-pay frequently see an increase in their clientele. You can see more clients as a provider if you work with multiple insurance companies, frequently at no cost to your clients.
Haley Goodrich, RD, LDN, owner of INSPIRD Nutrition Consulting, notes that accepting insurance “exponentially increases the number of people I can work with. It makes nutrition health care affordable for people while still allowing the provider to be reimbursed well.”
Kelly Ahearn, MS, RDN, CDN, of Indigenous Nutritionist, says that before her recent move abroad, accepting insurance opened doors to her as well. “Doctors were more interested in referring clients to me when they knew I accepted insurance. Patients found me directly from their insurance companies. It provided me with a chance to help those who didn’t want or have the means to pay out-of-pocket costs, and helped me to grow my practice and help more people, so it was a win-win.”
Before you’re prepared to take insurance on behalf of patients, it can take months to set up your private practice to accept insurance. However, there are plenty of resources: The Academy of Nutrition and Dietetics (the Academy) website’s “Getting Started With Payment” section contains links to both public and private resources for MNT reimbursement. 2. Knowing how to use the payment systems is crucial for delivering high-quality care, advocating for competitive pay for dietitians, and enhancing clients’ access to nutrition counseling, regardless of the method or methods you decide to use for your practice.
Public Insurance
In addition to self-pay and private insurance, RDs can accept public or government insurance on behalf of clients in the form of Medicare and Medicaid.
Medicare
US citizens 65 and older, as well as those under 65 with specific disabilities, can obtain insurance through Medicare, a federal health insurance program. For three years after a kidney transplant, Medicare covers people with kidney disease (apart from inpatient dialysis) and diabetes (all forms except prediabetes). Dietitians can influence this underserved and expanding population by requesting physician referrals by enrolling as Medicare Part B providers. Preventive care, lab testing, and doctor visits are all covered by Medicare Part B.
Medicare Part C offers the same benefits as Part B, but it is administered by private insurance companies through Health Maintenance Organization or Preferred Provider Organization plans. Referrals may be required for clients with Health Maintenance Organization plans from their
Medicaid
Millions of low-income Americans, including eligible adults, children, pregnant women, the elderly, and those with disabilities, are covered by Medicaid. Understanding Medicaid coverage, which is managed by the states and varies from one to the next, is also a good idea for dietitians.
Is Medicaid coverage available in New York? Does Medicaid cover obesity in California? What is the Medicaid reimbursement rate for Texas? Asking questions such as these and not knowing where to find the answers will lead to frustration. For example, in select states, Medicaid covers tele-health, nutrition counseling for pregnant women who are considered at risk nutritionally, and preventive nutrition assessments for children up to age 21. Yet, in other states, Medicaid may not cover such services. For a comprehensive comparison of what states will and will not cover, see the George Washington University department of health policy’s “Medicaid Fee-for-Service Treatment of Obesity Interventions.“
Although a smooth and efficient process would be ideal, dietitians should visit the Academy’s Leadership Directory to speak with their state’s Academy reimbursement representative. Your state representative can assist you in finding out whether Medicaid is an option for coverage in your state, whether state licensing is necessary, and other information. Healthy Bytes, a nutrition counseling reimbursement company, has also produced a “Nutrition Reimbursement State Guide” that includes comprehensive details on reimbursement rates and answers to frequently asked questions for each of the 50 states.
What’s on the Horizon?
Nutrition billing is complex and evolving quickly. Whether President Donald Trump will actually repeal the Affordable Care Act, as he hinted at during his campaign, remains to be seen. As of this writing, there was conjecture that he would keep shielding people with preexisting medical conditions from discrimination by insurance companies, but he might stop funding some parts of the law, like Medicaid expansion. The Republican party’s delay would allow the government time to create a replacement for the Affordable Care Act (ACA) rather than leaving millions of Americans without health insurance, though it is unclear how soon the law will be repealed. Republican proposals for a “repeal and delay,” which would take three years to implement, have been proposed since December 2016.
Dietitians who support Medicaid reimbursement for MNT may be impacted by these restrictions. According to Susan Paredez, MS, RD, CDN, the Academy’s reimbursement representative for New York, RDs face difficulties in her state because Medicaid does not currently reimburse for MNT. “RDNs have a unique opportunity to get involved in Governor Cuomo’s initiatives to improve health care for Medicaid recipients,” Paredez says. “This program, known as the Delivery System Reform Incentive Payment [DSRIP] Program, aims to decrease needless ER visits and hospital stays among Medicaid beneficiaries. She adds that DSRIP may provide funding for nutrition programs, saying, “This could be a model for the future of health care in this country.” Additionally, Paredez points out that after RDs are licensed
Getting Started
If you decide to accept insurance, what comes next? There are two main parts to getting set up with insurance: credentialing and contracting.
Credentialing
Credentialing means obtaining, verifying, and assessing the qualifications of a practitioner to make sure you meet their internal requirements for serving as a provider in their network. Credentials are licenses, education, training, experience, and other qualifications. Most insurance companies credential dietitians by using the information provided in the CAQH application. However, before you even attempt the application you will need to complete some steps.
To become an in-network provider, or “credentialed” with the carriers of your choice, you’ll need the following:
• an Employer Identification Number;
• a license (if required in your state);
• a National Provider Identifier (NPI); and
• liability insurance, which is available from Mercer Consumer Professional Liability Insurance for dietitians at a discounted rate through the Academy.
Setting up as a healthcare provider through the Council for Affordable Quality Healthcare ProView (CAQH) is also crucial. As a provider, the CAQH acts as a digital filing cabinet where you can safely keep your data. You can grant certain health plans access to your data for credentialing after entering your education and training, specializations and certifications, and basic personal information into the CAQH portal. Your authorized insurance companies will examine your CAQH and provide you with more details.
Credentialing is no small feat. According to Amy Roberts, PhD, CEO of Healthy Bytes, this process can take upwards of 20 hours to complete the required paperwork. This is why many either approach the process with endless patience, or they outsource the process to a company that has endless patience.
Contracting
The process of becoming an in-network provider with insurance companies is known as contracting. It also lays out the rules and regulations for plan members to follow when submitting claims. Find out if the insurance company is currently hiring new dietitians in your area by giving the provider services contact a call.
The contracting turnaround time varies depending on the insurance company. Some companies contract quickly in as little as one month, and some may take as long as six months.
Filing Claims 101
You can make your first claim as soon as you have a contract and credentials with one or more insurance companies in your state. Every claim will entail completing a benefits and eligibility check, submitting a claim, and receiving payment.
Conducting an Eligibility and Benefits Check
An eligibility check is used to verify the services that your patient’s health insurance covers. You’re checking to see whether the patient’s plan covers nutrition counseling services and any additional diagnosis codes. Get comfortable, as you may be on hold for a while, but once you reach a representative, the following are questions to ask:
• Are there diagnosis restrictions? Determine whether the visit is for preventive or another nutrition-related diagnosis, and inquire which procedure codes are covered by the plan.
• Is there a deductible? A deductible must be met before insurance companies will pay. It’s important to know whether patients have met their deductibles, because if they have, then they’ll be covered for services. If they have not, they’ll have to pay out-of-pocket until they meet their deductibles.
• Is there an out-of-pocket max? This is the amount that the client needs to reach before coinsurance kicks in.
• Are there additional co-payments or coinsurance? Co-payments may be required at each office visit even after deductibles are met. Coinsurance is the percentage of the service that the insurance company covers. This usually applies after the deductible and out-of-pocket maximum are met.
• Is a referral from a primary care provider required? Usually yes. Patients may need a form from their primary care provider giving them permission to see you for specialty services.
• Is there a maximum number of visits allowed? Determine whether there are restrictions on how many visits patients can have covered by insurance in the contract year. Be sure to clarify when the contract year starts.
• What’s the reference number for this call? In case the claim gets denied and you need to appeal it, a reference number will help you cite the information you were told on this call.
Filing a Claim
It’s time to bill the insurance carrier for your time with your patient.
If you opt to manage claims reimbursements on your own, you’ll need to become familiar with the Health Insurance Claim Form, or the CMS-1500 form, for claims filing. Dietitians may find the form at the Centers for Medicare & Medicaid Services website (www.cms.gov); this form is used for both private and public insurance. RD’s should ensure that during their time with clients they collect the necessary information to complete the form, eg, client contact information, DOB, reason for visit (diagnoses), insurance member ID number, relationship to insured, and signature. Following a client’s appointment, complete the form and file it electronically through a clearinghouse, or use a nutrition reimbursement company such as Healthy Bytes to assist. Dietitians can find a comprehensive explanation of claims filing in the Academy’s RDN’s Complete Guide to Credentialing and Billing: The Private Payer Market, available online and free for Academy members at eatrightstore.org.
There are two key code sets used to file claims: Current Procedural Terminology (CPT) codes and diagnosis codes (ICD-10-CM). These codes inform insurance companies what client services or procedures RDs provided.
For MNT, the following CPT codes are standard for private insurance, Medicare, and Medicaid and are the most common:
• 97802: MNT, initial assessment, individual, face-to-face with the patient, each 15 minutes;
• 97803: reassessment, individual, face-to-face with the patient, each 15 minutes; and
• 97804: group (two or more individuals) visit, each 30 minutes.
Diagnosis codes, on the other hand, are used to describe the conditions. When you receive a client referral from a medical provider, you must ask for the ICD-10 diagnosis code. One common code is Z71. for “Dietary counseling and surveillance”; however, all insurance types may not accept this code. The Academy publishes a list of codes you’ll likely use as a dietitian.
For Medicare, first use 97802, as long as another RD or health care provider didn’t use it for the patient within the past three years. Medicare covers three hours of MNT in the initial calendar year and two hours in subsequent years if patients have physician referrals. When you have exhausted benefits for the calendar year and the referring physician determines there’s a change in diagnosis for which dietary changes are necessary, then use the following “G” codes for the remainder of the calendar year:
• G0270: a 15-minute individual session for MNT reassessment and subsequent interventions following a second referral, in the same year for a change in diagnosis, medical condition, or treatment regimen; and
• G0271: a 30-minute group session for MNT reassessment and subsequent interventions following a second referral in the same year for a change in diagnosis, medical condition, or treatment regimen.
Medicaid coverage for MNT nutrition counseling related to obesity treatment varies so widely state by state that it’s best for dietitians to check with their state reimbursement representative to confirm coverage.
Getting Paid
Dietitians can still determine their billable rate if they decide to take insurance, but the insurance company will determine the reimbursement rate. Find out what a competitive rate is in your area, and if at all possible, ask the carrier for a higher level of reimbursement. Mandy Enright, MS, RDN, RYT, reimbursement chair for the Academy’s Nutrition Entrepreneurs Dietetic Practice Group, suggests RDs call their insurance carrier annually to discuss a reimbursement rate raise: “If you have a good relationship and see a lot of clients through a particular insurance company with whom you have been working for some time, reach out and ask for that raise. What have you got to lose?”
Reimbursement levels are competitive with what they were charging self-pay clients, according to many RDs. The time it takes for insurance companies to pay you can range from a few days to several weeks. Either a paper check or a direct deposit is used for payment.
Rates vary widely by carrier and state for private insurance reimbursement, but on average RDs can expect approximately $118/hour nationwide, according to Healthy Bytes’ data. Rates for Medicare and Medicaid reimbursement also vary state by state. For Medicare, Alaska currently has the highest initial appointment unit rate of $39.12/unit or $156.48/hour (RD nonfacility rate), while Arkansas and Missouri have the lowest initial appointment reimbursement rate at $27.80/unit or $111.20/hour.
Warnings, Mistakes, and Insider Tips
Even though you meticulously go through all the important steps necessary to file claims for reimbursement, keep in mind there will be times when claims are denied.
Denied Claims
Call the insurance company right away if a claim is rejected, and be prepared with the patient’s name, date of birth, member/client ID, claim ID, NPI number, tax ID number, and the service date of the denied claim. Find out how the claim is progressing and why it was rejected.
The following are several reasons why a claim may be denied:
Typos
Perhaps a simple error was made on the form, eg, you accidentally stated the diagnosis code as Z73.1 instead of Z71.3.
How to fix it: Each third-party payer has a different procedure for correcting errors. Contact the carrier to find out their preferred method or consult their website. Then refile a corrected claim.
Medicare Is the Primary Insurance
If a client’s primary insurance is Medicare, the secondary insurance carrier most likely will deny the claim.
How to fix it: Send the claim directly to Medicare with a GA modifier. RDs should use GA modifiers when they suspect services won’t be covered. Obtain a signed Advance Beneficiary Notice from the Medicare beneficiary to bill the patient. If the reason for the denial is “exhausted benefits,” obtain a new referral and use G codes. If you enter an ICD-10 code for which Medicare denies payment (eg, N18.9 for “chronic kidney disease, unspecified”), then the stage of kidney disease must be specified.
The Code Isn’t a Billable Service
In essence, the patient’s plan does not cover the procedure or diagnosis codes, or both.
How to fix it: Unfortunately, there’s no fix, but this can be avoided in the future by performing an eligibility check as described earlier. Request the client sign your office policy document that includes mention of their financial responsibility to pay you if their insurance doesn’t cover services.
The Claim Was Applied Toward a Deductible
Technically, the claim isn’t denied. The insurance company just won’t cover the client yet.
How to fix it: There isn’t a solution in this case, but by figuring out how much of the deductible has been paid thus far, an eligibility check can help avoid a surprise. Ask the customer to make the payment in cash.
Insurance Tips From the Pros
Sarah Koszyk, MA, RDN, founder of Family. Food. Fiesta., is no stranger to filing claims. One tip she offers to make claim filing run more smoothly is to write down the name of the person with whom you spoke when conducting an eligibility check, in addition to the date for your records. Make sure you confirm the ICD-10 and CPT codes you plan to submit with the representative. “This way, if the claim gets denied, you have proof when you call back to rectify,” Koszyk says.
Koszyk also suggests using a full nine-digit zip code for faster reimbursement. “I’ve had challenges submitting claims when I didn’t use the nine-digit zip code for billing. Before that I was using my five-digit zip code and they weren’t getting approved.“
Enright suggests conducting eligibility checks “in batches” rather than making a single call to the insurance carrier for each check. Before making the call, she gathers a few new clients every week. She will ask for confirmation of the patients’ diagnosis codes and CPT, the number of visits and units she can bill, whether any referrals or copays are required, whether her clients have a deductible to pay, and finally, whether there are any diagnosis codes that insurance does not cover. Verify whether a patient has previously seen a dietitian because some insurance companies will only pay for an initial RD visit once in a client’s lifetime. Each RD visit will only be covered for up to an hour by another carrier in her home state of New Jersey.
“I once had a Medicare client who had already seen an RD at another facility,” Enright says, “and thus a portion of my time was not eligible for reimbursement due to terms of my client’s coverage, as he had maxed out his nutrition counseling benefits for the year.”
This is where Enright could resubmit the client’s claim using G codes. Always ask Medicare beneficiaries whether they’ve seen an RD before coming to see you.
Reimbursement Alternatives
For certain private practices, accepting insurance might not be the best option. You alone know what’s best for your company. Alternatives to taking private insurance include the following:
• Paying out of pocket: Dietitians who choose not to accept insurance can request payment from clients in the form of cash, check, or credit card.
• Packaged services: Many RDs are offering a package of services at a discounted price.
• Health savings accounts or flexible spending accounts offered by a client’s employer as part of the client’s benefits package: Dietitians are accepting money from these types of sources as a form of payment.
• Superbills: In lieu of accepting insurance, RDs can encourage clients to submit claims for reimbursement on their own if they have out-of-network coverage and provide them with documentation for billing in the form of a superbill. This medical receipt should list diagnoses and MNT codes so patients can file with their insurance for direct payment.
You Don’t Have to Go It Alone
It might make sense to submit claims yourself if you see only one or two patients each week and you are already proficient in coding. This is especially true if you frequently see the same kinds of patients, like those who only have Blue Cross or have diabetes. If you only accept one insurance company and have the time to become familiar with the coding, it might also make sense to handle your own billing. The good news is that you don’t have to go it alone if you don’t want to.
There are billing companies that can manage credentialing and contracting, and insurance reimbursement and denied claims on your behalf. Outsourcing is a pot of gold for dietitians who either don’t have the time to manage the back-end paperwork involved with insurance or don’t want to.
One such business is Healthy Bytes. In addition to helping dietitians set up with insurance companies, Roberts and her team offer a comprehensive billing platform specifically tailored for nutrition counseling, enabling dietitians to electronically submit claims. With the help of sophisticated machine learning, Healthy Bytes expedites processing and minimizes errors, allowing dietitians to submit a claim in as little as 45 seconds. In the first year after becoming in-network providers, Roberts’ dietitian clients see a more than 300% increase in revenue.
Office Ally’s Practice Mate also offers free claims submission and processing services via their software. Their software features a dashboard for tracking claims and revenue, supporting multiple providers in a single office or among multiple offices, creating superbills, and managing payments and deposits using auto posting.
In the end, dietitians ought to seek out a billing company that focuses on nutrition counseling. As with any vendor, screen possible billers by looking into their reporting capabilities, fee schedule, and nutrition experience. Check for monthly fees and make sure you have a high enough volume to warrant using a biller, as many services have minimums. With the added benefit of real-time reporting, billing payment software is a good compromise for the majority of practices.
For those who have the resources, another option is to hire an assistant to manage billing and other office responsibilities.
Consult with other dietitians who have been accepting various forms of payment to learn more about what works best for them and why. Consider outsourcing reimbursement management if that seems like an attractive option for you. Rest assured that experts are available; if you need a copilot to help you make sense of your roadmap to reimbursement, seek one out.