1. Reimbursement Nutr 564: Summer 2007

2. Objectives n Define terms n Describe the function of reimbursement n Review strategic planning for reimbursement n Describe components u Covered services u Mechanisms n Review examples

3. Terms n Participating Provider A physician or practitioner who signs a participation agreement/contract to accept assignment on all claims submitted to Medicare

4. Terms n 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

5. Terms n 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 F A service or a supply that was never provided F 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 F A claim for a higher level of service F A claim for a service that was provided by an unlicensed/credentialed individual

6. u The Third Party System F 1st party = the patient F 2nd party = the provider F 3rd party = the insurer who manages the payment Terms

7. u Center for Medicare and Medicaid Services (CMS) F Largest health insurance program F 40 million Americans F Eligibility F 65 years of age or older F Some disable persons < 65 F End-Stage Renal Disease with dialysis or transplant Terms - Medicare

8. n Part A F Hospital Insurance FFunded by SS n Part B F Supplemental Medical Insurance F Doctor appointments F Other services and supplies F Funded by General Revenues and Premiums Terms - Medicare

9. n Part C FPrograms that might help an individual to pay health care costs that Medicare does not cover n Part D F Prescription drug costs Terms - Medicare

10. Title XIX of the Social Security Act - law in 1965 Administered by the States Medicaid

11. 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

12. Eligibility n Low income families with children n Aged, blind, disabled individuals who meet criteria n Infants born to Medicaid eligible pregnant women n Children < 6 and pregnant women at < 133% of the n Federal poverty level n Recipients of adoption assistance and foster care n Certain Medicare beneficiaries Medicaid

13. n Each of the States: n Establishes its own eligibility standards n Determines the type, amount, duration, and scope of services n Sets the rate of payment for services; and n Administers its own program Terms

14. ‘Medigap’ n Insurance that covers expenses outside of Medicare Terms

15. n What are the issues around reimbursement that warrant the inclusion of this topic as a knowledge and skill for the DPD? n Why?? Reimbursement

16. n What needs to be in place for successful reimbursement? Reimbursement n History – how has the profession evolved?

17. Components n Covered Services under CMS (Nov ’06) Medicare covers MNT services when: u Ordered by an MD u Conditions F Kidney disease not on dialysis F Kidney transplant F Diabetes u May be provided by F RD F ‘Medicare approved nutrition professional’ u Include: F Nutritional Assessment F Counseling

18. u Billing systems to connect the service to the compensation u Documentation system - Authorization F Documentation of nutrition risk F Care Pathways * Diagnosis * Age * Guidelines Mechanisms - Systems

19. u Standards F Who are qualified professionals to provide the service? RD Credential Continuing Education Regulatory oversight - Dept of Licensing Mechanisms - Billing

20. u Documentation system - INPUT Identifies 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

21. u Outpatient Billing - Codes F 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

22. u ICD codes International Classification of Diseases Diagnosis codes ICD - 9 CM Codes F HCFA (CMA) provides updates and training F 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

23. u ICD codes Example 250 codes for diabetes Physician sets the diagnosis Urbanski P: 2001 Mechanisms - Codes

24. Reimbursement u Barriers F Insurance Policies Medicaid policies for coverage Private insurers’ practices –Should be the same as Medicare or Medicaid F Changing regulations F Details of submitting a claim ICD codes F Lack of systematic feedback / QA

25. Reimbursement u Professional Activities F Support MNT Legislation F Keep informed F Communicate to your representatives

26. Reimbursement u Involve your clients F Ask about reimbursement experience Do they know if they got compensated? What has worked? F Share this information with other clients F Warn clients if insurance may not cover a service

27. CMS and Reimbursement n Requires credential u RD as defined by CDR u State licensure or certification n Must be licensed or certified in every state of practice n Must “Enroll” as a Medicare provider

28. Reimbursement - Examples u CPT Codes Common Procedural Coding system which defines actual procedure or service that the healthcare professional performed Level I Level II Urbanski P: 2001

29. Reimbursement - Examples u New CPT Codes for MNT 97802 = 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

30. Reimbursement - Examples n Relative Values Units (RVU) per 15 minute increment u Set at.46 RVUs per 15 min segment for 97802 and 97803 u Set at.18 RVUs per 30 min segment for 97804

31. Reimbursement u Provider Number F Each RD should have a provider number. u Forms F From 1-3 forms to complete depending on: practice setting employment relationship F The RD’s local carrier can assist in this process See http://www.hcfa.gov/Medicare/enrollment/contacts Urbanski P: 2001

32. CMS and ‘Opting Out’ Why A client with an eligible service need Medicare ProviderOpt Out

33. CMS and ‘Opting Out’ Medicare provider Pro u May be required by employer u Two-year opt-out period Con u Coverage at set reimbursement rate which is very low u Paperwork u Legally required to follow Medicare guidelines including F update bulletins

34. CMS and ‘Opting Out’ Opt-out u Better reimbursement

35. Reimbursement u Resources F American Dietetic Association Web site Annual Meeting - workshops F Dietetic Practice Groups Managers in Clinical Care Consultants in Dietetics F Dietetics List Serves Note: Specific discussion of fee rates is illegal. Equates to price fixing. F Networking with local practitioners

36. Wojtylak FR: Medicare enteral and parenteral reimbursement: requirements for successful coverage and payment. Support Line 8/06 Regulations - Examples

37. Matching Funds for Medicaid n What are the three options for Medicaid disease management? (Pritchett; JADA 04) n What does the chronic care model provide as a framework?

38. Enteral Documentation - Medicare n Method of administration (e.g., pump, syringe) n Appropriate diagnostic codes n Ongoing proof of delivery (supplier delivery records) n Ongoing proof of patient compliance (regular calls and clinician monitoring records/assessments) n Copy of CMN (enteral CMN) on file n Reasons for the need/use of any specialty enteral formulas

39. Additional Issues in Enteral Feeding n Specialized formulas need additional documentation n Inadequate documentation may mean a lower level of reimbursement ‘Down- coding’

40. Parenteral Coverage Conditions that do NOT qualify for PN under Medicare n Swallowing disorders n Temporary gastric emptying n Impaired nutrient intake n Anorexia related to metabolic disorder (e.g. cancer) n Impaired oral intake of food with physical disorder n Adverse effects of pharmacotherapy n End-stage renal disease

41. When Claims are denied