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