Professional Development | Jan 4 2018
Navigating Outpatient Reimbursement: What to Know to Grow Your Business
Medicare, Medicaid and Private Insurance, Oh My!
Whether you are operating your own private practice or employed through another healthcare provider, navigating the world of insurance, billing, and reimbursement for your services can seem daunting. Not sure where to start? Let Dietitians On Demand lend a helping hand, so that you can take your practice to the next level.
Before you schedule your first patient, make sure you have an active dietitian license for the state in which you are practicing (if required), liability insurance, and a National Provider Identifier (NPI) number. You can begin your NPI application here. To receive payment for outpatient medical nutrition therapy (MNT) counseling, there are four avenues to pursue: Medicare, Medicaid, private insurance, and private (or self) pay. Let’s start first with Medicare.
You can receive reimbursement for MNT counseling through Medicare Part B, which covers outpatient health services for individuals aged 65 and older or those younger than 65 with certain disabilities. Medicare covers MNT for individuals with diabetes mellitus (except prediabetes), kidney disease, and those who have received a kidney transplant for up to three years after the transplant operation. To register as a Medicare Part B provider, complete and submit the CMS-8551 form linked here.
Unlike Medicare, Medicaid coverage for MNT varies from state to state. To find out what is covered in your state, click here to view a state-by-state Medicaid coverage guide for nutrition-related care created by George Washington University’s Department of Health Policy. This guide focuses primarily on obesity-related services. To find out if additional MNT services are covered, contact your state’s Medicaid office.
To become an in-network provider for private insurance, there are two primary steps you must complete before you can begin filing claims.
Credentialing: This is essentially an application to private insurance companies to receive reimbursement from them for your MNT services. Be aware that this paperwork is often extremely lengthy and time-consuming (think: 30+ pages…). Thus, it may be worth your time to do some preliminary research first—which health insurance companies specifically would you like to work with and are they accepting new dietitian providers? Think about large employers in your area or your most common referring physicians. What insurance companies are they affiliated with? This may be a good place to start. You will want to register with the Council for Affordable Quality Healthcare (CAQH) ProView, which is an online portal to house all of the information about you, as a provider.You can allow specific health insurance companies to access this information during the credentialing process.Note that each insurance company may vary in the exact information they require.
Contracting: This is the actual process of becoming an in-network provider with a private insurance company (yay!). This may take up to several months and will define the rules for submitting claims for reimbursement.
Private (or Self) Pay
Whether or not you choose to accept any form of insurance, you will likely want to establish rates for patients who do not have MNT benefits or opt to pay out-of-pocket. These rates will vary depending on what type of services you provide, your geographical area, and your own personal business practices. You may consider the Medicare and Medicaid reimbursement rates, which vary by state, as a starting point. These rates have been compiled by Healthy Bytes and can be accessed at https://www.healthybytes.co/state-guide
As you work to expand your outpatient practice, have patience. Doing so will allow you to expand your clientele (and your wallet!).
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Ulatowski, K. Guide to insurance reimbursement. Today’s Dietitian. 2017;19(2):40. Accessed December 26, 2017 from http://www.todaysdietitian.com/newarchives/0217p40.shtml.
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