0dw whuvlq 017dqg'607 , qfuhdvlqj5 …wadepage.org/files/file/2012 annual...

12 Keys to

Financially

Sustaining

DSME and Other

Patient Education

Programs:

5 F’s and 7 P’s

Mary Ann Hodorowicz, RD, LDN, MBA, CDE

Certified Endocrinology Coder

Mary Ann Hodorowicz Consulting, LLC

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Slide 2 This information is intended for educational and reference purposes only. It does not

constitute legal, financial, medical or other professional advice.

The information does not necessarily reflect opinions, policies and/or official positions

of the Center for Medicare and Medicaid Services, private healthcare insurance

companies, or other professional associations. Information contained herein is subject

to change by these and other organizations at any moment, and is subject to

interpretation by its legal representatives, end users and recipients. Readers should

seek professional counsel for legal, ethical and business concerns. The information is

not a replacement for the Academy of Nutrition and Dietetics’ Nutrition Practice

Guidelines or American Diabetes Association’s Standards of Medical Care in Diabetes.

As always, the reader’s clinical judgment and expertise must be applied to any and all

information in this document.

Mary Ann Hodorowicz Consulting, LLC [email protected]

708-359-3864

Information on products below at: www.maryannhodorowicz.com

“Money Matters in MNT and DSMT: Increasing Reimbursement Success in All

Practice Settings, The Complete Guide ©”, 5th. Edition, 2012

“Establishing a Successful MNT Clinic in Any Practice Setting ©”

“EZ Forms for the Busy RD” ©: 107 total, on CD-r; Modifiable; MS Word

Package A: Diabetes and Hyperlipidemia MNT Intervention Forms, Plus 3

Free DSMT Assessment Form and MNT Superbills: 18 Forms

Package B: Diabetes and Hyperlipidemia MNT Chart Audit Worksheets: 5 Forms

Package C: MNT Surveys, Referrals, Flyer, Screening, Intake, Analysis and

Other Business/Office and Record Keeping Forms: 84 Forms

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Slide 3 Learning Objectives

• Name the 5 F’s for sustaining DSME programs and

other outpatient education programs in various

outpatient practice settings.

• Name the 7 P’s for sustaining DSME programs and

other outpatient education programs in various

outpatient practice settings.

• Name 4 of the many types of off-site locations where

out patient programs can be delivered.

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5 F’s

1. Financial bottom-line

2. Focus on billing basics

3. Format

4. Full Diabetes Services

5. First Rate Quality

Standards

7 P’s

1. Provider Status

2. Programs

3. Place

4. Promotion

5. Patient Centeredness

6. Practice Management

Essentials

7. Perfect Teamwork

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Slide 5 1. Financial Bottom-Line

Ask your team:

1. WHO is regularly identifying our program’s and

practice’s bottom-line? Is it someone from:

− Our own department?

− Accounting?

− Finance?

− Operations?

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Slide 6 1. Financial Bottom-Line, Cont.

Ask this person:

2. What exactly IS our program’s or practice’s

bottom line? Are we:

− Making money?

− Losing money?

− Breaking-even?

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1. Financial Bottom-Line, Cont.

If losing money, ask:

3. HOW can we fix it?

− Key word is “WE” !

− Your willingness to roll up your sleeves can

help:

− Save your program AND

− Save your job!

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Slide 8 1. Financial Bottom-Line, Cont.

4. Ask: “What expenses are charged to our program?”

− Request hard-copy of financial reports on regular

basis….example:

• Revenue and Expense Reports

• Income Statements

– Examine reports carefully and ask:

• Do these expenses really belong to our

program?

• Are they accurate and reasonable?

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Slide 9 2. Focus on Billing Basics

5. Ask billers and coders:

– Are ALL of our DSME/MNT visits being billed?

– Are ALL other services we furnish being billed?

− CGM?

− Insulin pump starts?

− Are services billed in

timely manner?

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2. Focus on Billing Basics, Cont.

6. On claims, is ALL coding correct?

− CPT procedure codes? Examples:

• MNT codes 97802, 97803, 97804,

− HCPCS procedure codes? Examples:

• MNT codes G0270, G0271

• DSME codes G0108, G0108

– Number of “units” of above codes entered?

• MNT 97802, 97803, G0270: 1 unit = 15 min.

• MNT 97804, G0271: 1 unit = 30 min.

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Slide 11 2. Focus on Billing Basics, Cont.

• DSME G0108, G0109: 1 unit = 30 min.

− Revenue codes (OP hospital only)

• 942 for Medicare DSME and MNT claims from

OP hospital setting

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− ICD-9 diagnosis codes?

• Is 5-digit diabetes dx code used on ALL

diabetes-related services to Medicare?

− Place of service codes? Examples:

• 11 = Office

• 12 = Home

• 13 = Assisted Living Facility

• 22 = Outpatient Hospital

• 31 = Skilled nursing facility

• 32 = Nursing facility

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2. Focus on Billing Basics, Cont.

On your claims:

7. Is primary ICD-9 diagnosis code (reason for

today’s visit) entered as the #1 dx code in

diagnosis field?

− Example: If pt’s visit for DSME, is 5-digit dx

code for diabetes entered as the #1 dx code?

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On your claims:

8. Does procedure code entered on claim “point to”

the matching/corresponding diagnosis code?

− Example: Procedure code G0109 (group DSME)

must “point to” the diabetes diagnosis code.

− If code “points to” hyperlipidemia diagnosis on

claim, claim will be rejected, as G0109 is for

DSME….this does not “match”.

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On your claims:

9. Are ALL the diagnoses documented on physician’s

referral actually entered in diagnosis field?

− They should be!

− Can affect payer’s decisions on:

− Medical necessity of service

− Approval of claim as payable, AND

− Amount of reimbursement

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2. Focus on Billing Basics, Cont

Ask your team:

10. Are we tracking our claims ourselves, via regular

“Reimbursement Tracking Reports” from IT to:

− Identify each claim’s payment status:

• Paid? Rejected? Denied?

– Determine if ALL services billed?

– Determine if ALL pt co-payments, deductibles

and OOP payments collected in timely manner?

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11. Re: claims that have been denied and rejected:

− Is your team AND your billers investigating these

claims to identify root problem(s)?

− Are root problems then fixed?

− Are these claims then:

• Re-billed in timely manner, OR

• Appealed?

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For more complete information on how to complete

CMS 1500 claim form, can access online:

Medicare Claims Processing Manual

Chapter 26 - Completing and Processing

Form CMS-1500 Data Set

Just copy and paste this URL into your browser:

www.cms.gov/manuals/downloads/clm104c26.pdf

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3. Format

Ask your team:

1. Is our time being used efficiently to pt volume and

payer reimbursement by:

– Doing more group DSME and MNT?

– Holding group programs in staggered starts in

several different locations?

– Doing shared medical appointments (SMAs)?

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Slide 20 4. Full Diabetes Services

Ask your team: Do we offer all needed services to pts?

− Medical nutrition therapy

− Weight loss program

− Exercise program

− BG pattern management

− Shared medical appointments

− Continuous glucose monitoring

− Insulin pump starts (CSII)

− Diabetes shoes

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Slide 21 4. Full Diabetes Services, Cont.

− Specialist consultants and/or their services:

• Endocrinologist

• Diabetologist

• Pedorthist

• Podiatrist

• Psychologist

• Ophthalmologist

• Nephrologist

• Gynecologist specializing in diabetes

− Point of care testing (instant A1c, lipids, etc.)

− Insulin and injectable medication initiation

− Pregnancy and GDM diabetes services

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5. First Rate Evidence-Based Quality

Standards

Sackett et al defined evidence-based medicine as:

“The conscientious, explicit, and judicious use of

clinically relevant research in making decisions

about the care of individual patients.” 1

1. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS:

Evidence-based medicine: what it is and what it isn’t. BMJ 312:71–72,

1996

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Slide 23 5. First Rate Evidence-Based Quality

Standards, Cont.

• Strengths of evidence-based medicine:

– Moves clinical practice:

FROM

– Anecdotal experience and expert opinion

TO

– Strong scientific foundation

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Slide 24 5. First Rate Evidence-Based Quality

Standards, Cont.

– Integrates clinical medicine with basic and clinical

research

– Enhances effectiveness and safety of diagnostic,

preventive and therapeutic measures. 2

2. Evidence-Based Diabetes Care, Herman, William H. MD, MPH, Clinical

Diabetes, January 2002 vol. 20 no. 1 22-23 doi: 10.2337/diaclin.20.1.22

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1. National Standards for DSME as guiding principles

– 10 evidence-based standards used to:

• Provide blue print to manage DSME program

• Optimize pt outcomes

• Ensure quality of entire DSME program from

both clinical and operational perspective

– Adherence to is required for accreditation of

DSME program by AADE and Amer Diab Assoc


Standards, Cont.

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Slide 26

2. Evidence-based standards of diabetes medical care:

− American Diabetes Association

− American College of Obstetricians and

Gynecologists

− American Association of Clinical Endocrinologists

− American College of Endocrinology

− World Health Organization

− National Institute of Diabetes and Digestive and

Kidney Diseases


Standards, Cont.

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Slide 27

• BUT, evidence-based standards (EBS) MUST be

incorporated with:

– HCP’s JET

• Judgment….Experience…..Training

– Pt’s

• IV’s

– Issues….Values….Variables

• NEWS

– Needs….Expectations….Willingness….

Stage of readiness


Standards, Cont.

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EBS

HCP’s

J.E.T.

Pt’s

I.V.s and

N.E.W.S.

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Slide 29 1. Provider Status

1. IF they CAN be, are members of your DSME team

in-network providers for:

• Medicare?

• Medicaid?

• Larger private payers in area?

2. IF in-network private payer status NOT allowed,

have they asked private payers if they can bill as

out-of-network providers?

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Slide 30 1. Provider Status, Cont.

3. Or, do you practice M.B.A.?

− Management By Assumptions?

• Assume that private payers do NOT credential

RDs as in-network providers for MNT or

nutrition counseling, so don’t make call?

• Assume you cannot bill as out-of-network

provider, so don’t make the call?

M.B.A. can leave LOTS of YOUR earned money in

the pockets of the payers! Not good!

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1. Provider Status, Cont.

Remember:

• MOST large private payers pay for MNT or nutrition

counseling in diseases for which evidence exists

that diet in integral part of treatment plan

• 46 states have state insurance laws mandating

payment for DSME

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Slide 32 2. Programs

Think out of the box……ask your team:

1. Do we TYPES of programs to patient volume?

When insurance rates

Then patient volume must

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Slide 33 2. Programs, Cont.

2. Do we do other programs 100% compatible

with our core program (DSME)?

– MNT program?

– Weight loss program?

– Behavior change program?

– Exercise program?

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2. Programs, Cont.

– Monthly 1 hour “hot topic” community programs

for a small OOP fee? Examples:

− Nov: How to Avoid Holiday Weight Gain

− Dec: Healthy Baking Tips for the Holidays

− Jan: Lose Pounds the Healthy Weigh

− Feb: Heart Healthy Chocolate Desserts

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Slide 35 2. Programs, Cont.

3. Do we charge OPP fees or bill insurers for these

other patient programs?

– Many private payers now reimburse for these

– Many patients will pay out of pocket

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Slide 36 3. Place

Ask your team:

1. Do we bring our education programs TO our pts in:

– Malls (open “Health Stores”)?

– Employers’ place of business?

– Physician offices?

– Clinics (free-standing + inside big-box stores)?

– Libraries?

– Senior centers?

– Recreation departments?

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4. Promotion

Ask your team:

1. Do we do any marketing to physicians, mid-levels

and community to let them know we exist?

2. Do we maintain on-going communication with

referring physician/mid-level after each pt visit?

3. Do we promote completion of/encourage pts to

complete ALL billable hours of DSME program

and hours of other covered benefits, such as MNT?

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Slide 38 4. Promotion, Cont.

4. Do we focus our marketing efforts on our 4 main

target markets?

Existing patients

Physicians

Mid-levels: NP’s, PA’s, CNS’s

Community people

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Slide 39 4. Promotion, Cont.

5. What TYPES of marketing are used, do we

TRACK effectiveness? Do we VARY types?

− Pads of customize referral forms?

− Deliver pads to physicians’ offices in person?

− Tri-fold marketing brochures or slim jims for

placement on office reception desks, local

health fairs, employer groups, etc.?

− Create our website?

6. How OFTEN to we implement each type?

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5. Patient Centeredness

Ask your team:

1. Do we ensure medical care, DSME, and all education

programs based on patients’ needs, not office

schedule or curriculum?

– This pt outcomes and patient volume as it:

• Leads to revenue, via in “R and R”:

– Referrals to DSME and other programs

– Retention of patients in education programs

Patient

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Slide 41 5. Patient-Centeredness, Cont.

Primary

Care

Physician

Diabetes

Educators

Physician

Specialists

Support

Networks

Insurance

Company

2 Way Communication: Up and Down

Patient

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Slide 42 5. Patient Centeredness, Cont.

2. Do we use the more pt-centered counseling styles?

– Motivational Interviewing (MI)?

– Patient Empowerment (PE)?

3. Do we incorporate Adult Learning and Retention

(ALR) principles when counseling in group and 1:1?

Patient

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5. Patient Centeredness, Cont.

Example of teaching aid that embraces ALL 3

key counseling styles & principles: MI, PE, ALR:

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Slide 44 6. Practice Management Essentials

(PMEs)

PMEs maximize these

key areas in your practice:

A - E - I - O - U

Essentials

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Slide 45

A = Adherence to quality standards:

– Standards of practice

– Standards of professional performance

– Diabetes standards of care

– National standards of DSME

– Evidence-based nutrition practice

guidelines

6. Practice Management Essentials

(PMEs), Cont.

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E = Expense control

E = Ethics in management

– Operations

– Clinical

– Financial

E = Efficiency


(PMEs), Cont.

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Slide 47

I = Income

– Insurance reimbursement

– Patient OOP payments

– Patient deductibles and co-payments


(PMEs), Cont.

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Slide 48

O = Outcomes of patients

– Knowledge

– Behavior

– Clinical

– Cost-Savings (Financial)

– Satisfaction

• Patient

• Physician

• Payer


(PMEs), Cont.

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U = Utilization of all resources to the maximum:

– CGM equipment

– Insulin pump initiations

– POC testing…example:

• Instant A1c, BG, u.microalbumin, lipids, BP

– EMR and other software

– Shared medical appointments

– All pt education programs, in addition to DSME

– Services of consultant specialists


(PMEs), Cont.

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Slide 50

Just what are

Practice

Management

Essentials?


(PMEs), Cont.

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Slide 51

1. Initiate and maintain on-going communication with

patients, physicians and payers

2. Ensure ALL requirements of provider-insurer

contracts and coverage provisions are met

3. Develop policies & procedures (P&Ps)

that ensure consistency with:

– Standards of professional practice/performance

– Licensure/certification requirements

– Insurers’ coverage guidelines

– Patients’ rights, responsibilities, expectations


(PMEs), Cont.

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4. Attempt to become in-network credentialed provider

with private insurers

− Compile database of insurer-specific coverage

conditions for each service to be delivered

5. Implement HIPPA compliant systems that meet all

CMS’, government, state and federal statutes

6. Develop records storage and retrieval systems that

assure clear, accurate and timely documentation of

all services delivered


(PMEs), Cont.

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Slide 53

7. Implement financial systems that ensure complete,

accurate & timely billing and collections procedures

8. Implement CQI/quality management system at all

levels of and types of service delivery

9. Implement regular in-house training of clinical and

administrative staff on all elements of ethical billing

10. Review/renegotiate provider-insurer contracts with

insurers at least annually


(PMEs), Cont.

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Slide 54

11. Implement clinical systems that are 100%

compliant with:

− Standards of professional practice/performance

− Current evidence-based standards of:

• Medical care for diseases/conditions treated

• Medical nutrition therapy

• Diabetes self-management training

• CGM

• Insulin pump training


(PMEs), Cont.

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7. Perfect Team Communication

and Collaboration

• Perfecting your team communication and

collaboration allows your DSME program and

other education programs to thrive….not just

survive!

• T. E. A. M. S.U.C.C.E.S.S. T.O. L.A.S.T.

spells out exactly what your team needs to do…

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Slide 56 T Take the ‘Golden Rule’ to heart.

E Ensure all business information is shared with ALL

team members in timely manner.

A Avoid team member ‘turf wars’ at all costs!

There’s a place for everyone,

and everyone has their place!

M Make decisions based on fact, not assumptions.

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Slide 57 S Show respect always, even when disagreeing.

U Understand that the ‘blame game’ is destructive to

team communication and collaboration.

C Compliment one another often, and say ‘thank you’.

C Consider both sides of patient-educator conflict…

disgruntled pt doesn’t necessarily mean educator is

at fault.

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E Ensure team members make collaborative decisions

based on democracy…

NOT autocratic rule.

S Share ALL patient information is shared with ALL

team members on a timely basis.

S Separate your personal issues and business and

patient issues when at work.

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Slide 59 T Tackle team problems team (whether personal,

business or patient-related) to reduce/resolve ASAP

‘Stewing and brewing’ only intensifies the issue.

O Opt for a policy of never criticizing team members

to patients, staff, administration …and especially to

each of the other members.

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Slide 60 L Listen to each other (much different from ‘hearing’).

We’ll read poem about listening skills later.

A Arrange team meetings at least once per month.

S Stick to the rules…and that means everyone!

What’s good for the goose is good for the gander!”

T Tame down gossip (trim back the grape vine!)

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Don’t Be ‘Deaf’ To Good Listening Skills!

Listen well, a key for team success!

Quite different from what you ‘hear’!

First, do admit your biases,

And second, from judgment stay clear.

Third, dry subjects don’t tune out,

And fourth, ask questions when in doubt!

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Slide 62 Fifth, while others speak, do not multi-task,

A sign that listening skills you surely lack!

And refrain from planning what to say next,

It will put your comprehension to the test!

To ensure the message you do hear,

Keep a pad of paper very near!

Take good notes, as it’s a good bet,

That team communication will be met!

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Slide 63 Embracing these 5 F’s and 7 P’s

will help insure your goal of

making your DSME Program and

other patient education programs

financially sustainable!

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0dw whuvlq 017dqg'607 , qfuhdvlqj5 …wadepage.org/files/file/2012 annual...

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