February 2017 Issue

Guide to Insurance and Reimbursement
By Krista Ulatowski, MPH, RDN
Today's Dietitian
Vol. 19, No. 2, P. 40

Today's Dietitian provides practical steps to filing claims, coding, and getting paid.

Ask new private practice dietitians about one of the most challenging tasks they face in establishing their businesses, and they'll likely wrinkle their noses and say "insurance." Yes, getting credentialed and contracted with private practice insurance companies certainly can be challenging, but it doesn't have to be daunting. Navigating the reimbursement maze on behalf of clients and patients also can be tricky, but the following guide provides a roadmap to help.

Why Accept Insurance?
There are several reasons for dietitians to accept insurance instead of choosing to have clients pay out of pocket. The Affordable Care Act (ACA) improved access to preventive services for the general patient population. Nutrition counseling is widely covered by many insurance plans.

The emphasis on preventive services makes it possible to obtain reimbursement for services with an A or B rating by the US Preventive Services Task Force. These include "healthy diet counseling" and "obesity screening and counseling," which were more difficult in the past.1

Dietitians who accept insurance make their services available to clients who may be unable to afford care otherwise. Some dietitians, however, opt to take self-pay clients only, citing that accepting insurance may lead to more no-shows or cancellations if clients aren't "on the hook" and paying via cash, check, or credit card.

However, dietitians who have moved from self-pay to accepting insurance often see growth in their practices. Being a provider using a variety of insurance companies increases the number of clients you can see, often at no cost to clients.

Haley Goodrich, RD, LDN, owner of INSPIRD Nutrition Consulting, notes that accepting insurance "exponentially increases the number of people I am able to 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."

Setting up a private practice to accept insurance is time-consuming and can take months to complete before you're ready to accept insurance on behalf of patients. But resources abound: Resources for MNT reimbursement, both public and private, can be found at "Getting Started With Payment" on the Academy of Nutrition and Dietetics (the Academy) website.2 Whatever method(s) you choose for your practice, knowing how to navigate the payment systems is important to provide high-quality care, advocate for competitive pay for dietitians, and improve clients' access to nutrition counseling.

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 is a federal health insurance program that provides insurance for US citizens aged 65 and older, as well as those younger than 65 with certain disabilities. Medicare covers individuals with diabetes (all types except prediabetes) and kidney disease (except inpatient dialysis) and for three years following a kidney transplant. By becoming Medicare Part B providers, dietitians can seek referrals from physicians and make a difference in this growing and underserved population. Medicare Part B covers outpatient medical care such as doctor visits, lab tests, and preventive care.

Medicare Part C provides the same benefits as Medicare Part B but through private insurance companies via Preferred Provider Organization plans or Health Maintenance Organization plans. Clients with Health Maintenance Organization plans may need referrals from their primary health care providers before visiting dietitians. Apply for enrollment with your state's Medicare carriers by completing the CMS-855I form at cms.gov through the Provider Enrollment, Chain and Ownership System. For more information, visit the Academy's "Medicare Basics for RDNs" webpage: http://www.eatrightpro.org/resource/practice/getting-paid/getting-started-with-payment/medicare-basics.3

Medicaid provides health coverage to millions of low-income Americans, including eligible adults, children, pregnant women, the elderly, and people with disabilities. As dietitians, it's also wise to understand Medicaid coverage, which is administered by states and thus varies state to state.

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 telehealth, 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."4

It would be ideal if everything was streamlined and efficient, but until then dietitians should consult their Academy reimbursement representative for their state by visiting the Academy's Leadership Directory.5 Your state rep can help you ascertain whether state licensure is required, whether Medicaid is an option for coverage in your state, and more. In addition, nutrition counseling reimbursement firm Healthy Bytes has created a "Nutrition Reimbursement State Guide" with detailed information about reimbursement rates and answers to more common questions for all 50 states.6

What's on the Horizon?
Nutrition billing is complicated and rapidly changing. Time will tell whether President Donald Trump will repeal the ACA as he alluded to during his campaign. As of this writing, there was speculation that he would continue to protect individuals with preexisting health conditions from discrimination by insurers, yet he may defund certain aspects of the law such as restricting Medicaid expansion. It's unknown how quickly the ACA will be repealed; however, the Republican party's delay would give government time to develop its replacement instead of leaving millions of Americans without medical coverage. Since December 2016, Republicans have been suggesting a "repeal and delay," which would take three years to put into effect.

Such limitations could affect dietitians who are advocating for Medicaid reimbursement for MNT. Susan Paredez, MS, RD, CDN, who serves as the Academy's reimbursement representative for New York, says that in her state RDs are challenged since Medicaid currently doesn't reimburse for MNT. "Governor Cuomo's initiatives to improve health care for Medicaid recipients presents a unique opportunity for RDNs to get involved," Paredez says. "This initiative is called the Delivery System Reform Incentive Payment [DSRIP] Program, and its goal is to reduce unnecessary hospital admissions and emergency department visits by Medicaid recipients. This could be a model for the future of health care in this country," she says, adding that DSRIP may allocate funds for nutrition initiatives. Paredez also notes that once RDs receive licensure in the state of New York, Medicaid coverage for MNT may follow.

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.

To become an in-network provider, otherwise known as becoming "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.

In addition, it's key to get set up as a health care provider via the Council for Affordable Quality Healthcare ProView (CAQH). The CAQH serves as a digital filing cabinet where you can securely store your information as a provider. Once you enter your basic personal information, education and training, and specialties and certifications into the CAQH portal, you can authorize specific health plans to access your information for credentialing. Insurance companies you authorize will review your CAQH and send you further information.

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 is the process of becoming an in-network provider with insurance companies. It also establishes the policies and guidelines for filing claims for plan members. Call and ask the provider services contact whether the insurance company is currently accepting new dietitians in your area.

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
Once you're credentialed and contracted with one or more insurance companies in your state, you're ready to file your first claim. Each claim filed will involve conducting an eligibility and benefits check, filing a claim, and getting paid.

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? Learn 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 has to 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 haven't, they'll have to pay out-of-pocket until they meet their deductibles.
Is there an out-of-pocket max? This information is the amount that the client needs to reach before coinsurance kicks in.
Are there additional copayments or coinsurance? Copayments 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 have been met.
Is a referral from a primary care provider required? 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? Inquire 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 face 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 can find the form at the Centers for Medicare & Medicaid Services website (www.cms.gov); this form is used for both private and public insurance. RDs should ensure that during their time with clients they collect the necessary information to complete the form, eg, client contact information, date of birth, 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 commonly used:

97802: MNT, initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes;
97803: reassessment and intervention, 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 conditions. When you receive a client referral from a medical provider, you must ask for the ICD-10 diagnosis code. One common code is Z71.3 for "Dietary counseling and surveillance"; however, all insurance types may not accept this code. The Academy publishes a list of codes you're likely to use as a dietitian.7

For Medicare, first use 97802 as long as another RD or health care provider didn't use it for the patient within the last 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
When dietitians choose to accept insurance, they can still set their billable rate, but the insurance company will set the reimbursement rate. Research what's considered a competitive rate for your geographic location, and when possible, negotiate for a higher reimbursement level from the carrier. 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?"

Many RDs find that reimbursement levels are competitive with what they were charging self-pay clients. It can take anywhere from a few days to a few weeks to receive payment from insurance companies. Payment is either made via paper check or direct deposit.

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.8

Pitfalls, 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
If a claim is denied, call the insurance company immediately and have the following information ready: your NPI number, tax ID number, patient's name, date of birth, member/client ID, and claim ID, and the service date of the denied claim. Inquire about the status of the claim and the reason for denial.

The following are several reasons why a claim may be denied:

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
Essentially, the procedure or diagnosis codes (or both) aren't covered under the patient's plan.

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: In this instance, there's no fix, but an eligibility check can prevent such a surprise by determining how much of the deductible has been met to date. Request the client pay out-of-pocket.

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 and time 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 speedier 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. She amasses a few new clients each week before placing the call, during which she'll ask for verification of patients' CPT and diagnosis codes, the number of units and visits that she can bill, whether there are any copays or referrals needed, whether her clients have a deductible to meet, and lastly, whether there are any diagnosis codes that insurance doesn't cover. Some companies will cover an initial RD visit just once in a client's lifetime, so make sure to check whether a patient has seen a dietitian in the past. Another carrier in her state of New Jersey will cover each RD visit only up to one hour.

"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
Accepting insurance may not be the right choice for every private practice. Only you know what's best for your business. The following are alternatives to accepting private insurance:

Paying out of pocket, or self-pay: 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 cash 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
If you're seeing one or two patients per week and you're already comfortable with coding, it may make sense to file claims yourself. This is particularly true if you see the same types of patients all the time, such as those with diabetes or those only with Blue Cross. It also may make sense to do your own billing if you accept only one insurance company and have time to learn the coding. However, if you don't want to go it alone, the good news is that you don't have 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.

Healthy Bytes is one such company. Roberts and her team help dietitians get set up with insurance companies and provide a full-service billing platform designed for nutrition counseling so dietitians can submit claims electronically. Powered by advanced machine learning, Healthy Bytes reduces errors and speeds processing, taking dietitians only 45 seconds to file a claim. Roberts notes that her dietitian clients who become in-network providers increase their revenues by more than 300% within the first year.

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.

Ultimately, dietitians should look for a billing firm that specializes in nutrition counseling. Vet potential billers as you would any vendor by researching their nutrition experience, fee structure, and reporting capabilities. Many services tend to come with minimums, so check for monthly fees and make sure you have a high enough volume to justify using a biller. Billing payment software is a nice middle ground for most practices and comes with the added bonus of real-time reporting.

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.

— Krista Ulatowski, MPH, RDN, owner of KUcumber Nutrition Communications, creates and implements marketing, communications, social media, and public relations programs for RDs and food companies. She wishes to disclose that Healthy Bytes is one of her clients. She also wishes to thank Ann M. Silver, MS, RDN, CDE, CDN, for her review and contributions to this article.

1. Health care reform and preventive services. Academy of Nutrition and Dietetics website. http://www.eatrightpro.org/resource/advocacy/disease-prevention-and-treatment/access-to-health-care/healthcare-reform-and-preventive-services. Accessed December 1, 2016.

2. Getting started with payment. Academy of Nutrition and Dietetics website. http://www.eatrightpro.org/resources/practice/getting-paid/getting-started-with-payment. Accessed December 1, 2016.

3. Medicare basics for RDNs: becoming a provider. Academy of Nutrition and Dietetics website.
http://www.eatrightpro.org/resource/practice/getting-paid/getting-started-with-payment/medicare-basics. Accessed December 1, 2016.

4. George Washington University Department of Health Policy. Medicaid fee-for-service treatment of obesity interventions: 50 state & District of Columbia survey. http://stopobesityalliance.org/wp-content/themes/stopobesityalliance/pdfs/Medicaid_Fee-For-Service_Treatment_of_Obesity_Intervention.pdf. Accessed December 16, 2016.

5. Leadership directory. Academy of Nutrition and Dietetics website.
http://www.eatrightpro.org/leadershipdirectory. Accessed December 1, 2016.

6. Nutrition reimbursement state guide. Healthy Bytes website. http://www.eatrightpro.org/resource/leadership/volunteering/committees-and-task-forces/leadership-directory. Accessed December 1, 2016.

7. ICD-10-CM. Academy of Nutrition and Dietetics website. http://www.eatrightpro.org/resource/practice/getting-paid/nuts-and-bolts-of-getting-paid/icd-10-cm. Accessed December 1, 2016.

8. Academy of Nutrition and Dietetics. Medicare fee schedule. http://www.eatrightpro.org/~/media/eatrightpro%20files/practice/patient%20care/medical%20nutrition%20therapy/mnt/news%20and%20events/medicare-fee-schedule.ashx. Accessed December 17, 2016.