Reimbursement Guidelines for Dietitians in New Hampshire and Pre-Diabetes Education Grant...
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Transcript of Reimbursement Guidelines for Dietitians in New Hampshire and Pre-Diabetes Education Grant...
Reimbursement Guidelines for Dietitians in New Hampshireand Pre-Diabetes Education Grant
Independent Study byBarrie Lynne SuttonDietetic Intern 2015
Objectives: Educate NHDA Members on Insurance Reimbursement, Obtaining an NPI
and Credentialing with Insurance Companies
Research Credentialing Processes for Cigna, Anthem, Harvard Pilgrim, Aetna, Medicaid, NH Healthy Families, and Well Sense
List Coverage Available Through Medicaid Managed Companies NH Healthy Families and Well Sense
Explain Medicare Nutrition Benefits
Explain Medicaid Nutrition and Diabetes Self-Management Coverage
Request Permission from North Carolina Dietetic Association to Adapt their Billing Guide for New Hampshire
Meet with Private Practice Dietitians
Participate in Advocacy and Introduction of HR 1686 Preventing Diabetes in Medicare Act
Submit Grant Proposal for Pre-Diabetes Education Funding
Objectives:
Target Population for the Reimbursement Guide: NHDA Members
Plan of Action:1) Request permissions from the authors of the North
Carolina Billing Guide
2) Research process of obtaining NPI
3) Research process of credentialing with insurance companies
4) Research CAQH (Council for Affordable Quality Healthcare)
5) Research common insurance companies’ credentialing processes in New Hampshire (Cigna, Anthem, Harvard Pilgrim, Medicaid, Aetna)
6) Research EIN, professional liability insurance, etc..
NPI(National Provider Identifier Number) 10-digit intelligence free identifier number used for financial and
administrative purposes
Every provider has a unique identifier number
Introduced following HIPPA regulations to keep information, such as provider specialty and location, off of financial and administrative paperwork
Credentialing with Insurance Companies
Every insurance company may have a unique credentialing process
Begin credentialing process 6 months before beginning to see clients, as it can be time consuming
Identify which insurance companies are most popular in your area◦ In NH: Anthem, Aetna, Harvard Pilgrim, Cigna,
Medicaid
CredentialingVisit the website for each individual
insurance company for credentialing instructions
Many insurance companies now credential through a “common credentialing application” known as the Council for Affordable Quality Healthcare (CAQH)
CAQH
Online service intended to eliminate need for credentialing individually with every insurance company
Benefits◦Time Saving◦Minimizes Paperwork◦Keeps Information Current◦Free Service
Employer Identification Number(EIN)
A nine-digit number assigned by the IRS
Required for certain individuals who do not have employees and employers to file various business tax returns
If you and/or your business does not require an EIN, you will file using your SSN
EIN: Do You Need One?
EIN Application
Found on the IRS website in the Small Business and Self-Employed Sections
Apply by:◦Online Application (preferred) ◦Fax◦Telephone◦Mail
Sole Proprietorship
You might consider this if you do not have interest in hiring employees or obtaining an EIN
In this case, a SSN may be used in place of an EIN only if your business…◦Has no employees and is not required to file excise, employment, alcohol, tobacco, or firearms tax returns
Sole ProprietorshipAdvantages…
◦Ability to deduct your business losses to the extent of your total income from all sources Interest, dividends, and gains from sales of non-
business property◦Avoid paying doubles taxes
Personal income taxes + business taxes on same dollar income
Reasons to explore using other business entities…◦As a sole proprietor, you are personally liable
for all of the debts of your sole proprietorship
◦Higher income taxes because you must report your business income on your personal tax return
Covered Benefits
Medicare◦Medicare Part B covers MNT for certain cases
Diabetes (type 1 or type 2 ONLY) Kidney Disease Kidney Transplant in last 36 months Doctor Referral Required
Medicaid◦Does not cover dietary services for weight loss,
nutritional counseling, and exercise programs
NH Healthy Families◦Same coverage as Medicaid plus additional
approved services◦MNT covered with no listed Prior Authorization or
limitations noted
Well Sense◦Covers what Medicaid requires plus additional
authorized services◦MNT covered with Prior Authorization that deems it
as necessary◦Reimbursement up to $200 for gym memberships
and Weight Watchers programs◦Dietary services for commercial weight loss and
exercise programs not covered
Bill HR 1686: Preventing Diabetes Through Medicare Act
Currently Medicare only covers MNT for Type 1 and Type 2 DiabetesNOT Pre-Diabetes
Bill proposed to extend MNT coverage for individuals diagnosed with Pre-Diabetes
Preventing Diabetes Through Medicare Act
29.1 million (1 out of 10) Americans have diabetes
86 million Americans estimated to have pre-diabetes
Preventing Diabetes Through Medicare Act
7 out of 10 people who are aged 65 or older, and eligible for Medicare are affected by diabetes or pre-diabetes
◦For 5 out of 10 of these people, diabetes may be prevented with access to lifestyle intervention, such as MNT provided by a registered dietitian
NH Diabetes Statistics
In 2007 about 5% of NH residents had diabetes, of these half were covered by Medicare
Most recent statistics show 7% of NH residents now have diabetes
By 2050 the CDC estimates as many as 1 in 3 people will have diabetes
Medical Expenses of DiabetesMedical expenses for those with diabetes
is 2.3 times higher than for those without. Why?◦Medications◦Complications
Vision loss Renal disease Heart disease Limb amputations Death
Medical Expenses of Diabetes
In 2009 the total cost of diabetes and its complications exceeded $876 million
◦Two-thirds of this cost is the direct result of medical bills
◦One-third of this cost is from indirect costs Lost work productivity Disability Pre-mature death
What Can We Do?Advocate and Support the Bill HR 1686:
Preventing Diabetes Through Medicare Act
◦Access for individuals to MNT with an RD when diagnosed with pre-diabetes
◦Reduce the risk of developing Type 2 Diabetes
◦Reduce overall tax money being used to treat diabetes and put money towards preventative measures, which cost less in the long run
Grant
Allen Foundation◦Funds non-profit organizations and nutrition
educations programs
◦Proposed program would be 12 one-hour class sessions held once a month for individuals at risk for developing type 2 diabetes or who have pre-diabetes
◦Classes would be taught by a Dietitian with aid from Dietetic Interns
GrantClasses would cover making healthy food
choices, portion sizes, and focusing on making lifestyle changes to reduce the risk of type 2 diabetes
Classes would be designed to incorporate goal-setting to encourage participants and provide accountability
Work for Future Interns:Continue researching and writing
Reimbursement Guide elements◦Contacting insurance companies as needed
Follow up need and feasibility to create nutrition education modules for pre-diabetes
Follow up the progress of Bill HR 1686
Resources:
National Plan and Provider Enumeration System. “How to Apply for an NPI”. Accessed 20 Apr 2015. https://nppes.cms.hhs.gov/NPPES/Welcome.do
Justia US Law. “2014New Hampshire Revised Statutes Chapter 420-J: Managed Care Law. Accessed 20 Apr 2015. http://law.justia.com/codes/new-hampshire/2013/title-xxxvii/chapter-420-j/section-420-j-4
Anthem Blue Cross Blue Shield. “Join Our Network”. Accessed 21 Apr 2015. https://www.anthem.com/wps/portal/ahpprovider?content_path=provider/nh/f6/s0/t0/pw_e229317.htm&rootLevel=5&state=nh&label=Join%20Our%20Networks
Cigna. “Credentialing and Recredentialing”. Accessed 22 Apr 2015. http://www.cigna.com/healthcare-professionals/resources-for-health-care-professionals/doing-business-with-cigna/credentialing-and-recredentialing?WT.z_nav=healthcare-professionals%2Fresources-for-health-care-professionals%2Fdoing-business-with-cigna%2Fhealth-provider-practice-management-tools%3BBody%3Bcredentialing%20process
Harvard Pilgrim. “Join Harvard Pilgrim’s Provider Network”. Accessed 22 Apr 2015. https://www.harvardpilgrim.org/portal/page?_pageid=253,1117993&_dad=portal&_schema=PORTAL
Aetna. “Medical Application Request Form.” Accessed 23 Apr 2015. https://www.aetna.com/health-care-professionals/forms/medical-application.html
Medicare. “Details for CMS 855I”. Accessed 24 Apr 2015. http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS019477.html?DLPage=1&DLEntries=10&DLFilter=855&DLSort=0&DLSortDir=ascending
Resources: New Hampshire Healthy Families. “Become a Provider”. Accessed 24 Apr 2015.
http://www.nhhealthyfamilies.com/for-providers/become-a-provider/ Well Sense. “Credentialing and Provider Enrollment Process.” Accessed 25 Apr 2015. http://
www.wellsense.org/providers/join-our-network Council for Affordable Quality Healthcare. “About CAQH”. Accessed 25 Apr 2015. http://
www.caqh.org/about/about-caqh Internal Revenue Services. “Apply for an Employer Identification Number (EIN)”. Accessed 7 Jul
2015. http://www.irs.gov/Businesses/Small-Businesses-&-Self-Employed/Apply-for-an-Employer-Identification-Number-(EIN)-Online