reimbursement nutr 564: summer 2007. objectives n define terms n describe the function of...
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ReimbursementNutr 564: Summer 2007
Objectives Define terms Describe the function of
reimbursement Review strategic planning for
reimbursement Describe components
Covered services Mechanisms
Review examples
Terms Participating Provider
A physician or practitioner who signs a participation agreement/contract to accept assignment on all claims submitted to Medicare
Terms Health Care Provider (HIPAA)
Any provider of medial or other health services, or supplies, who transmits any health information in electronic form in connection with a transaction for which standard requirements have been adopted.
Note – as of 2003 Medicare is prohibited by law from paying paper claims except for small providers
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
The Third Party System 1st party = the patient 2nd party = the provider 3rd party = the insurer who
manages the payment
Terms
Center for Medicare and Medicaid Services (CMS) Largest health insurance program 40 million Americans Eligibility
65 years of age or older Some disable persons < 65 End-Stage Renal Disease with dialysis or
transplant
Terms - Medicare
Part A Hospital Insurance Funded by SS
Part B Supplemental Medical Insurance Doctor appointments Other services and supplies Funded by General Revenues and
Premiums
Terms - Medicare
Part C Programs that might help an individual to
pay health care costs that Medicare does not cover
Part D Prescription drug costs
Terms - Medicare
Title XIX of the Social Security Act - law in 1965
Administered by the States
Medicaid
Medicaid is a state administered program and each state sets its own guidelines regarding eligibility and services. http://www.cms.hhs.gov/medicaid/consumer.asp
Terms
Eligibility Low income families with children Aged, blind, disabled individuals who meet
criteria Infants born to Medicaid eligible pregnant
women Children < 6 and pregnant women at <
133% of the Federal poverty level Recipients of adoption assistance and
foster care Certain Medicare beneficiaries
Medicaid
Medicaid Each of the States:
Establishes its own eligibility standards
Determines the type, amount, duration, and scope of services
Sets the rate of payment for services; and
Administers its own program
Terms
‘Medigap’
Insurance that covers expenses outside of Medicare
Terms
What are the issues around reimbursement that warrant the inclusion of this topic as a knowledge and skill for the DPD?
Why??
Reimbursement
What needs to be in place for successful reimbursement?
Reimbursement
History – how has the profession evolved?
Components Covered Services under CMS (Nov ’06)
Medicare covers MNT services when: Ordered by an MD Conditions
Kidney disease not on dialysis Kidney transplant Diabetes
May be provided by RD ‘Medicare approved nutrition professional’
Include: Nutritional Assessment Counseling
Billing systems to connect the service to the compensation
Documentation system - Authorization Documentation of nutrition risk Care Pathways
* Diagnosis
* Age
* Guidelines
Mechanisms - Systems
Standards Who are qualified professionals to
provide the service? RD Credential
Continuing Education
Regulatory oversight - Dept of Licensing
Mechanisms - Billing
Documentation system - INPUTIdentifies the type of service provided
Nutrition Counseling
Identifies the scope of the intervention
Initial Assessment
Follow-up
Identifies the duration
15 min intervals
Mechanisms - Billing
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
Mechanisms - Codes
ICD codesInternational 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
Mechanisms - Codes
ICD codesExample
250 codes for diabetes
Physician sets the diagnosis
Urbanski P: 2001
Mechanisms - Codes
Reimbursement Barriers
Insurance Policies• Medicaid policies for coverage• Private insurers’ practices
– Should be the same as Medicare or Medicaid
Changing regulationsDetails of submitting a claim
• ICD codes
Lack of systematic feedback / QA
Reimbursement Professional Activities
Support MNT LegislationKeep informedCommunicate 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 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 - Examples 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 - Examples
New CPT Codes for MNT97802 = 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 - Examples
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 process
See 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
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
Wojtylak FR: Medicare enteral and parenteral reimbursement: requirements for successful coverage and payment. Support Line 8/06
Regulations - Examples
Matching Funds for Medicaid
What are the three options for Medicaid disease management? (Pritchett; JADA 04)
What does the chronic care model provide as a framework?
Enteral Documentation - Medicare
Method of administration (e.g., pump, syringe) Appropriate diagnostic codes Ongoing proof of delivery (supplier delivery
records) Ongoing proof of patient compliance (regular calls
and clinician monitoring records/assessments) Copy of CMN (enteral CMN) on file Reasons for the need/use of any specialty enteral
formulas
Additional Issues in Enteral Feeding Specialized formulas need additional
documentation Inadequate documentation may mean
a lower level of reimbursement ‘Down-coding’
Parenteral Coverage
Conditions that do NOT qualify for PN under Medicare
Swallowing disorders Temporary gastric emptying Impaired nutrient intake Anorexia related to metabolic disorder (e.g.
cancer) Impaired oral intake of food with physical disorder Adverse effects of pharmacotherapy End-stage renal disease
When Claims are denied