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Session 1: Becoming An In-Network Insurance Provider

In the last few years with the Affordable Care Act, nutrition counseling has become more widely covered by many health plans across the country, with more medical conditions and higher number of visits that are now being reimbursed. Since 2015, nutrition counseling is considered an essential benefit in 26 states under preventative services, so areas like weight management, hypertension, and other areas that were not previously covered can now be reimbursed.  In some of the major health plans in certain states, unlimited visits are even fully covered.

 
 

Becoming an in-network provider enables private practices to grow quickly because it increases your likelihood of clients and gives you a 62% higher chance of converting a paying client when compared to private pay.  Let’s step through some of the ways to get started if you are considering becoming an in-network provider.

1. Research reimbursement in your area

Begin by making a list of all of the insurance companies in your city and state, so you can find their contact information to inquire about their coverage.  One great place to start is searching by state on eHealthInsurance. Another good place to start is with some of the major national health plans, which include: 

  • Aetna
  • Cigna
  • Blue Cross Blue Shield
  • Anthem
  • United HealthCare

Medicare is also another great option to accept insurance. While they are limited to coverage for Diabetes and Renal disease (and if done in a primary care setting, obesity counseling), it is definitely still worth becoming a Medicare provider because the 65+ age group will be the ones are most likely the ones who will need nutrition counseling.

Once you've made your list, contact each health insurance company to obtain an application to become a network provider and find out the following before proceeding:

  • Network status in accepting dietitians
  • Contract terms
  • Eligible medical conditions
  • Fee schedules

Most of the time, dietitians find that contracted rates are very comparable to private pay rates. To get a better idea, you can find out what the average reimbursement rate is for your local area by looking at the Medicare Fee schedule, which is typically the average rate of insurance reimbursable rates in the specified location and set at 85% of the reimbursed physician rate.

 

2. Credentialing

Once you’ve determined that you can proceed in becoming an in-network provider with a health insurance company, the next phase is to become credentialed.  Before you begin this process, your business entity must be appropriately set up as the following are part of the required information that you must submit:

  • EIN
  • NPI
  • Proof of liability insurance

Note: Please refer to Module 2 if you need to go through all the appropriate steps of setting up your private practice

CAQH also provides a standardized application to make it easier to be credentialed with multiple health plans with one application process. Your CAQH information can be stored and maintained for submission to your selected health plan organizations. This can help save you time by allowing health plans to directly access your credentialing information.

*Note: You still have to contact each insurance company to obtain and fill out a specific application for each, which will then permit the insurance company to use your CAQH information.

3. Contracting

Once the credentialing portion is submitted to the health insurance company and the provider network is open, you will move into the contracting phase with the health insurance company.  

The contracting phase can be a lengthy process, and in general, can take anywhere between 2 to 8 months. Sometimes, you may even find out that the provider network becomes limited or closes while you are waiting. It is also helpful to apply to multiple insurance companies at once, as you will be more likely to get through the process with at least one insurance company to jumpstart your practice while you wait on the others.

While you are waiting to hear back, you can consider the following: 

  • Advertise on your website that you are in the process of credentialing to become an in-network provider. 
  • Consider starting a wait list for clients who want to use insurance to work with you, and inform them to set up an appointment as soon as you confirm with the insurance company.

Once you are successfully contracted with an insurance company, the next steps are as follows:

  • They will contact you and send over paperwork for your signature through email or regular mail.  
  • Ask them to provide a date in which you will become active in their system. This is the day that you can begin accepting insurance-covered clients and submitting claims.
  • Each insurance company will list you on their provider directory so that their insurance members will be able to find you.

 

 

Getting help with credentialing and contracting

If you don’t want to deal with the hassle of paperwork insurance credentialing and contracting services, such as Healthy Bytes, offer services that help dietitians with the credentialing and contracting paperwork for a fee, as well as a HIPAA-compliant online platform where you can submit and receive eligibility checks for your patients and quickly submit claims.

  • Contact them and see if they are the right fit in helping you contracted with insurance, help you negotiate a competitive contract rate, and make it easier to submit claims with their service so you can focus less on claims paperwork and more on your clients!  
  • We highly recommend you checking on your own on the status of any open networks before deciding to use Healthy Bytes' contracting service. Even with the help of Healthy Bytes your ability to get contracted is ultimately on whether the insurance company has opened their network, which can sometimes be a very narrow window.  

What if you can't become contracted as an in-network provider?

As some of you may have found, certain states are difficult to become contracted with major health plans. The typical rule of thumb is that if your state does not have licensure, you may find that networks are closed often times for stand-alone private practice dietitians. 

One way that you may be able to become an in-network provider is to go under the umbrella of an existing health care practice that already accepts health insurance (whether it be a medical, chiropractic, or a dietetic practice). That means going through the lengthy credentialing and contracting process under another practice in order to starting seeing their patients; you will also be employed as a contractor or employee by the practice.  Owners of the existing practice may take ~20-40% rate for patient consultations billed through their practice. Part of that cost may include: 

  • Liability insurance coverage (Note: this would only cover liability for patients you see through their practice.)
  • Helping you handle your claims billing
  • Office space

Despite taking a fee or rate, it may be a great way to help you jumpstart a client base and is a viable option to consider. View this as a partnership situation where they may be helping you gain momentum to start seeing clients through another practitioner's patient base.



Session 2: Logistics of Insurance Billing

Before I was able to submit my first claim, I needed to understand what all the insurance lingo meant. Another huge barrier I encountered was talking with insurance representatives on the phone. Everything can seem quite intimidating as a new provider and the representatives themselves can be vague in the information they provide and the information can even vary from one representative to the next. In this session, I will be discussing what you need to know about filing claims for your clients.

 
 

 

1. Learning the insurance vocabulary

Being an in-network provider means you must first familiarize yourself with the jargon. Healthy Bytes has provided a comprehensive list that you can reference and bookmark whenever you have any questions.

 

2. Perform eligibility checks

Performing an eligibility check is absolutely essential prior to meeting with a new client so you will know exactly what their coverage is or if they even have insurance coverage. This will allow you to collect any copays or coinsurance payments at the time of their appointment.

Beyond that, medical insurance is confusing to most people. The client will feel much more comfortable if you take the time to explain their coverage to them. If the client has to meet their deductible before the claim will be reimbursable, I always contact the client before the day of the appointment to let them know how much they will owe and why.

Here are a few tips for performing eligibility checks:

1. Always record a reference number when talking with a representative.

  • When performing eligibility checks, record the reference number for the call, the name of the representative, and all of the information the representative gives you.
  • The best place to document this information is in the client’s medical chart.
  • Reference numbers are very helpful to have anytime you need to appeal a claim.

2. Have all the information you will need to perform an eligibility check in front of you when calling an insurance company.

  • Your EIN or NPI
  • Client’s member ID
  • Client's date of birth
  • Client's address
  • Client's diagnosis and procedure codes

Tip: Creating a list of frequently-used diagnosis codes as you see more patients can save you time in the long run!

3. Submitting your claims

One advantage to using an EMR such as Kalix, is the built-in billing features to create standard insurance claim forms. Claim forms are then submitted to a separate clearinghouse, such as Office Ally to bill your claims to different insurance companies. 

Medical billing clearinghouses help take claim information from a billing service or provider, check the claims for errors, and send this claim information electronically to insurance companies. Claims sent electronically are paid much faster than paper claims.

Another efficient way to submit claims is using Healthy Bytes for your full billing and insurance needs. They will help with eligibility checks for new clients as well as claim submissions in real time. Using Healthy Bytes will not require the extra step of using a clearinghouse. 

 

9 additional tips for accepting insurance

1. Prior to their initial consultation, obtain the client’s full insurance information when setting them up as a new client and run an eligibility check using the codes you will be billing with.  

2. Make sure the client understands there is always a chance the insurance company will not accept part of or all of the claim.

3. Be sure to obtain information for both primary and secondary insurances if they have both. 

4. Medicare will only cover for renal disease and diabetes diagnoses. If a client has Medicare as their primary insurance and you know the claim will be rejected but would like to use their secondary insurance, you must still submit the claim to Medicare first. 

5. Medicaid will not cover Medical Nutrition Therapy with a Registered Dietitian.

6. When performing an eligibility check, ask the representative the following:

  • Diagnosis restrictions
  • Number of visits they will cover per year
  • Copay or coinsurance
  • Is there a deductible that has to be met?
  • Is there a need for a physician referral?

7. Note in your medical record when your client’s calendar year for their plan starts over. This will be important for whether their deductible applies and starts over.

8. After submitting claims, check Explanation of Benefits (EOBs) frequently to make sure you are being paid correctly. If a claim has been rejected or not paid correctly, you must resubmit it. This may take some investigating before re-submitting.

9. Balance billing is generally illegal. Balance billing is when an in-network provider bills the client for the difference between a provider's private pay rate and the contracted amount of the insurance company. The provider also cannot bill the client if they feel the insurance company is taking too long to pay.



Session 3: Accepting Private Pay Clients

Accepting health insurance as an in-network provider isn’t for everyone, whether that be based on a personal business decision or due to closed insurance networks in your area. In this session, we’ll go over a few different business strategies for determining your private pay rate for nutrition counseling and other strategies for out-of-pocket services.

 
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The most common problem that most dietitians face is understanding what your private pay rate for nutrition counseling should be.  It is a fine art between getting paid a fair market rate while finding the rate at which the consumer market will bear.  You don’t want to undervalue yourself, but you also want to be realistic with what the consumer may be willing to pay. 

1. Setting a baseline

The first step is to start researching what other private practice RDs in cities similar to yours are charging out-of-pocket.  Ask your contacts, or go on their websites for their listed prices.  You will start getting a better idea about the price range that you may begin to consider. 

Even though you are not going through health insurance, we recommend using the Medicare Fee Schedule Rates as a way to objectively assess what the going average market rate is for your profession in your area. The Medicare fee schedule is calculated based on a relative average fee and gives you a starting baseline of understanding what your going contracted rate is for health plans. 

Once you establish what the average or baseline range for dietitians is, that is your starting point where you can begin testing out your rates and seeing whether people are willing to pay it. A few reminders:

  • Do not be afraid to charge what you are worth, but also be realistic about what people are willing to pay based on your experience and marketing reach.
  • If you are just starting out, you may want to consider lowering your rate by 15-20%, until you can get a few testimonials in.  
  • Make sure the discounted clients understand that these are special promotional rates so they can understand its true value.
  • In addition to single session rates, consider providing packages of bundled sessions.   You can consider marketing these packages as a defined program, and you can set your client's expectations that you will guide them through a specific goal, with the allotted number of sessions or time frame. This helps put a short-term, attainable goal in context for the client because they know what they are trying to achieve with the package they are paying for.

2. When to start increasing the price

As you start building more word-of-mouth referrals, beginning to see a steady influx of clients for 6-12 months, or seeing more inquiries due to increasing popularity through different digital, press, and social media channels, you can consider raising your introductory rates.

However, be careful to not raise it too suddenly! Having 10K followers on Instagram won’t necessarily mean they will pay your higher rates. Here are a few things to consider:

  • Do it through small increments of 10-15%, and see if that changes the amount of business or inquiries that you are receiving. This will help you make sure that people are WILLING to pay those rates, even as they increase.
  • Increasing your price can also be a strategy when there are too many requests for you to handle, so you can decrease your session volume and work only with quality clients who are willing to make the higher investment in you.

 

3. Other ways to monetize through private pay clients

People love to have items to hold or events to experience.  By keeping this in mind, prospective clients may likely value your advice even more when it’s provided in the context of something that is seemingly more tangible. In addition to counseling sessions, you can also consider offering the following private pay packages:

  • Cooking classes - Experiential learning and direct application of how your client will live through your advice. 
  • Kitchen makeovers - Help them restock their kitchen with the essentials so they don’t have to think about it.  Make sure you include the cost of restocking within your price, and you can bundle your counseling rate within it.  
  • Grocery tours - Take them to a grocery store and guide them through the shopping experience.  Teaching them how to read labels as you go, and again, like the kitchen makeover, make sure you include the cost of their groceries within your pricing so you can bundle your rate.  That does mean that you have to price out what you will buy at the store ahead of time, and have a general budget for the groceries.

Make sure there is purpose for each of these packages and a value-add that they understand is included. They need to understand what they are learning from this experience, how they will gain value from it, and why they need you to help them.  

Simply telling them, I will tell you ‘how to shop’ is not really a value, but telling them ‘how to shop so they will feel more confident and knowledgeable in creating healthier budget meals for their whole family’ is definitely more valuable!

Having more tangible items that they can take away from the experience will also add value to those packages, so be sure to highlight that. For example, describing your grocery tour that comes with "$100 value of premium grocery items for one week to create 7 days of breakfast, lunch, and dinner’ is much more tangible to your customer than simply saying “Grocery Tour”.