Should I Become a Provider Under a Specific Insurance Policy or Remain Out of Network?

Some things to keep in mind:

• Not all insurers allow RDNs to be preferred providers for medical nutrition therapy (MNT)

• Some health plans limit the number of RDNs on their panel to serve their beneficiaries.

• Some insurers limit coverage on the number of visits per year/lifetime

Many insurances cover MNT, diabetes self-management training and wellness benefits. This can be a great opportunity to become an in-network provider.

There are several different models in practice with insurers that you can consider:

• Become a direct provider and bill for MNT

• RDN place of service and billing entity must be outpatient hospital, clinic or medical providers’ office

• RDN MNT benefits may, in special circumstances, be billed incident to physician fees. (For Medicare this is forbidden except for Intensive Behavioral Therapy for Obesity; Intensive Behavioral Therapy for CVD)

Consider the mix of payers for clients in your area to determine your practice model.

Investigate:

• How services are covered if an insurance plan is offered

• If referrals are needed from the physician

• If beneficiaries can self-refer

• How much is reimbursed per visit

• Billing deadlines

• What CPT codes are accepted for services rendered

• What ICD10 codes are recognized for reimbursement

• How long the contracting process is before seeing a beneficiary & bill

If you decided not to become a plan’s provider/not eligible to become an in-network provider, you can ask if the beneficiaries have out-of-network benefits (covered benefits, paid at a different rate if the provider is not paneled). Verify these benefits with the member or provider services representative at the health plan. The payment may be sent to the member, you may wish to obtain payment up-front from the clients and the reimbursement check will be sent directly to them.Obtaining payment from a client after out of network services are rendered is challenging.

As always, check with your accountant and legal professional on the best business model for you.

No matter where you are in developing your practice, we are here to help! Schedule your free introductory coaching call to discuss your practice and goals further.