Betsy La Forge, MPH Blue Cross and Blue Shield of North Carolina

Health insurance reimbursement 101 Health Care Reform Blue Cross and Blue Shield of North Carolina –

our approach and success with Medical Nutrition Therapy (MNT) coverage

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Federal and State mandates/regulations Medicare Clinical guidelines, clinical effectiveness,

standards of care Proven ROI/cost-effectiveness The competition Employer group, provider and patient

expectations/demands Managing escalating health care costs

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The Affordable Care Act Grandfathered plans USPSTF CPT/HCPCS ICD – 9 NPI Credentialed In-network ASO/Self-insured business HDHP Copayment, co-insurance, deductible

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Passed in March 2010 Objectives: Increase access to health insurance Implement insurance reforms Improve health care quality Curb rapidly rising health care costs

Staggered implementation through 2018 – the biggest changes are in 2014

Many changes already made, such as mandated coverage of preventive services at 100% implemented in 2010

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Mandated coverage of “Recommended Preventive Services*”

100% coverage - no cost-sharing when furnished by an in-network provider

Applies to non-grandfathered group health plans including insured and self-insured plans (ASO), as well as individual and family policies

*Evidence-based care: Rated “A” or “B” by USPSTF (US Preventive Services Task Force)

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President Obama campaigned on the promise that “if you like your current health care plan, you can keep it.”

The ACA allows plans in effect prior to March 23, 2010 to be “grandfathered” and exempt from certain ACA requirements.

Grandfathered plans are exempt from: Preventive Care covered at 100%

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Includes several nutrition-related provisions:

Counseling for a healthy diet Intensive dietary counseling for adults with hyperlipidemia and

other known risk factors for diet-related chronic disease

Screening and counseling for obesity: adults and children over age 6 Already in place - Screen for obesity and offer intensive

counseling and behavioral interventions New June 2013 – for adults with BMI of 30 or greater, clinicians

should provide or refer patients to intensive, multi-component behavioral interventions

New in 2012 - Breastfeeding support, supplies and counseling

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Medicare patients are eligible for "intensive behavioral therapy for obesity" from primary care providers in a primary care setting if their (BMI) is >30

They are entitled to 1 face-to-face counseling visit each week for a month, followed by a face-to-face session every other week for an additional 5 months.

If a patient has lost at least 6.6 pounds (3kg) during the first 6 months of counseling, he or she is entitled to an additional visit every month for another 6 months. For patients who fail to lose the required weight, "a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period," according to CMS.

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CMS will allow coverage for Face-to-Face Behavioral Counseling for Obesity, 15 minutes, G0447, along with 1 of the ICD-9 codes for BMI 30.0-BMI 70 (V85.30-V85.39 and V85.41-V85.45), only when services are submitted by the following provider specialties:

01 - General Practice 08 - Family Practice 11 - Internal Medicine 16 - Obstetrics/Gynecology 37 - Pediatric Medicine 38 - Geriatric Medicine 50 - Nurse Practitioner 89 - Certified Clinical Nurse Specialist 97 - Physician Assistant

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11- Physician’s office 22- Outpatient clinic 49- Independent clinic 71-State or local public health clinic

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The correct procedure (CPT or HCPCS) code The patient must have the appropriate

diagnosis (ICD-9) The type of provider The place of service The frequency and number of visits allowed The number of units/amount of time allowed

per visit Whether the provider is in or out of network

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CPT/ HCPCS

Description BCBSNC Covers for RD’s

97802 MNT, individual, initial assessment, 15 min increments Yes

97803 MNT, individual, re-assessment, 15 min increments Yes

97804 MNT, group, 30 min increments Yes

S9465 Diabetic Management Program Yes

S9470 Nutritional counseling, diet Yes

G02070 MNT, individual re-assessment for change in diagnosis, condition or treatment, 15 min increments

Yes

G0108 Diabetes self- management training, individual, 30 min increments

Yes

G0109 Diabetes self-management training, group, 30 min increments

Yes

G0447 Intensive Behavioral Therapy for Obesity No

99211 Breast Feeding education and coaching No 15

Medicare coverage is fairly clear-cut, reimbursement rates vary by region

Medicaid coverage varies from state to state Private insurers must interpret state and federal

mandates and establish their own terms of coverage Benefits can vary greatly Benefits can vary from state to state even among the

same insurance carrier The type of insurance plan (PPO, HMO, HSA, POS) will

impact coverage ASO (self-funded) status and grandfather status also

impacts coverage

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CPT or HCPCS Diagnosis (ICD –9) Allowed Per Benefit Period

BCBS Kansas - Adults

97802-97804 278.00,278.01,V85.30- V85.39, V85.4, V65.3

6 hours

BCBS Kansas – Children

97802-97804 V85.54 26 hours

BCBSNC – Non-Grandfathered Plans

99385-99387,99395-99397,96150-96155, 99401-99404 or G0447

BCBSNC– Grandfathered Plans

97802 - 97804 6 visits

Medicare G0447 V85.30-V85.39, V85.41 – V85.45

22 visits

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2013 Obesity Counseling Medicare Allowables for Behavior Counsel Obesity 15m G0447

(all states, National Payment Amount)

http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

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http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx 20

Get an NPI Find out if any plans credential RD’s in your state

and which MNT services they cover Get to know the Provider Relations staff at the

health plans you work with Learn from other RD’s in your state Know how to read a member’s insurance ID card

▪ Will indicate the Product the member has (PPO, HSA, etc)

▪ Will have relevant phone numbers

▪ Has the member name and ID, which you will need for billing

Consider hiring a coding expert

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Medicare recognized obesity as a medical condition (2005)

Overall recognition of implications by employers & policy makers In 2005, BCBSNC began credentialing and contracting with

licensed Registered Dietitians Six MNT visits covered per year as a component of the BCBSNC

disease/health management programs The co-pay for MNT is waived BCBSNC conducted a study with the ADA to determine cost-

effectiveness of MNT on weight loss In 2010 BCBSNC deems nutrition counseling a preventive service

covered at 100% and MNT coverage is expanded to unlimited visits without diagnosis restrictions

2012 BCBSNC increased reimbursement levels for MNT

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Credentialing is the process by which an insurance company evaluates education, training and other relevant information of health care providers to verify that they meet the standards for providing services to insured members

Credentialing regulations can vary by state Providers must become re-credentialed every 3 years Contracting is a separate process, which follows

credentialing Once a health care provider enters into a contract with an

insurance company, they become “in-network”

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25

22

70

110

160

210

278

0

50

100

150

200

250

300

2005 2006 2007 2008 2009 2010

# of in-network

RDs

Year

26

524

4,476

10,823

16,199 18,206

20,860

25,758

39,475

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

2005 2006 2007 2008 2009 2010 2011 2012

MNT Visits

per Year

Year

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Data from 8 health plans and large employer groups that are part of the Healthier Generation Benefit study (MNT services covered for overweight children)

2013 Emory University

BCBSNC – actively recruits RD’s and promotes the service

This organization dropped co-pays for use of the benefit

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The Incremental Value of Medical Nutritional Therapy in Weight Management

Managed Care/January 2013

BCBSNC, Duke University, & ADA collaboration Conclusion: MNT is a valuable adjunct to health management

programs and can be implemented for a relatively low cost. MNT warrants serious consideration as a standard inclusion in health benefit plans.

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2-year, retrospective, case – controlled study Overweight or obese individuals, 18 or older Enrolled in the BCBSNC health management

program between 2006 - 2008 Cases = participants who received MNT within 4

weeks of enrolling (n= 291)

Controls = matched controls who enrolled but did not seek MNT (n=1104)

Both groups received weight management educational materials and tools

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Parameter Group Baseline Follow-up Difference Statistical significance

Weight

in kg; mean (SD)

MNT 94.0

(20.4) 90.9

(21.2) -3.1

(10.6)

t(278)= -4.9, p <.001

NoMNT 94.6

(21.1) 93.1

(21.9)

-1.4 (12.3)

t(1051)= -3.7, p<.001

BMI; mean (SD)

MNT 33.4 (6.0)

32.3 (6.3)

-1.1 (3.8)

t(278)= -4.9, p<.001

NoMNT 33.9 (6.6)

33.5 (6.9)

-0.4 (4.3)

t(1041)= -2.9, p=.004

Waist Circ

cm; mean (SD)

MNT 103.3 (14.1)

100.4 (13.1)

-2.9 t(134)= -2.8,

p=.006

NoMNT 101.4 (14.2)

100.2 (14.1)

-1.1 t(501)= -2.1,

p=.034 31

Out-come baseline to follow-up

MNT Group

No MNT Group

Un-adjusted Group Difference

Statistical Significance Adjusted Difference Between Groups

Weight (kg)

-3.1 -1.4 11.7 β = -1.75, t(1314) = -2.21,

p=.028

BMI -1.1 -0.4 -0.7

β = -0.79, t(1314) = -2.88,

p=.004

Waist (cm) -2.9 -1.1 -1.8 NS

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Individuals who received MNT had twice the odds of achieving a clinically significant weight loss (5% or more)

5% of the health management program group chose MNT

Those who selected MNT averaged ~2.6 RD visits

The higher utilizers averaged 3.9 visits

The incremental cost of MNT was $0.03 PMPM

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Health care reform may offer increased opportunities for RD’s

Work within your state Associations and through national organizations to increase the visibility of RD’s

Look for opportunities to “prove” your value Learn as much as you can about how health

insurance works or partner with someone who knows

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ACA - The Affordable Care Act, a federal law that went into effect in March 2010. Also known as “Obama Care”.

ASO or Self-insured business - An arrangement in which an employer hires a third party to deliver administrative services to the employer such as claims processing and billing; the employer bears the risk for claims.

Copayment - A copayment is a flat rate fee paid for office visits or prescription medications. Copayments are usually collected at the time of service.

CPT/HCPCS – Procedure codes (what type of service was provided). Credentialing (or medical credentialing or "provider credentialing") - Is the

process of establishing the qualifications of licensed professionals, organizational members or organizations, and assessing their background and legitimacy.

Deductible - The out of pocket dollar amount paid each benefit period for covered medical services before the insurance begins paying toward those medical services. Deductibles do not apply to preventive care services under ACA.

Grandfathered plans – Insurance plans that were in effect prior to March 23, 2010 and exempt from certain ACA requirements.

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HDHP -High deductible health plan, a health insurance plan with lower premiums and higher deductibles than a traditional health plan. Being covered by an HDHP is also a requirement for having a health saving account. Some HDHP plans offer additional "wellness" benefits, provided before a deductible is paid. Providers do not collect a co-payment upfront with this type of plan.

ICD – 9 – Diagnostic codes (which condition does the patient have). In-network Provider – An in-network provider is one contracted with

the health insurance company to provide services to plan members for specific pre-negotiated rates.

NPI – National Provider Identifier. A standard unique identifier for health care providers. Go to https://nppes.cms.hhs.gov/NPPES/ to apply.

USPSTF – US Preventive Services Task Force. Created in 1984, the U.S. Preventive Services Task Force is an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services.

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