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Barriers to Maintaining an Accredited Diabetes Education Program

May 26, 2015

Since becoming accredited in November 2011, our internal medicine practice has billed but has not received reimbursement for DSMT. It is difficult to maintain a program when revenue is not being generated and we have considered suspending our accreditation program. 

Our biller is not having much luck at finding the reason we are not being reimbursed. Possible reasons for lack of reimbursement include problems in the clearinghouse, deductibles not having been met, and one insurance company simply told us DSMT is not reimbursed. We definitely will continue to provide diabetes education but outcomes need to be collected to maintain accreditation.

As the nurse practitioner and diabetes educator, I can generate more revenue for the practice serving as the nurse practitioner treating patients instead of being in the CDE role providing DSMT. We have been conducting shared medical appointments but because no billing code exists for such visits, no outcomes are collected and reported. Accreditation was the means by which we want to show our outcomes to Medicare and insurance carriers. 

At this point, we have decreased our diabetes education sessions to a four-hour period once a week until we make a definite decision to continue or suspend the program. My understanding is that some programs charge a flat fee for DSMT and don’t even bother billing insurance; however, the majority of our patients are older adults who are on Medicare. They are already responsible for the yearly deductible and the 20 percent not covered by Medicare so paying for diabetes education is not a priority.

In Texas, there are ongoing reimbursement issues with Medicaid and many practices are having difficulty remaining open which compounds the problem of trying to keep our accredited program financially viable.

Is anyone else having reimbursement issues or if you have, how were you able to solve them?

8 comments

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  1. Apr 30, 2012

    Unfortunately your problem is not unique. I am a PharmD,CDE and I work in a federally qualified health clinic, but we are experienceing the same challenges. I think what needs to happen is a push to make CDEs medical providers in some way rather than try to accredit the programs themselves. Pharmacists face this challenge not just with diabetes but all chronic disease management programs because we keep certifying, accrediting, etc the program and not the person. I think your situation is shared by many others and I think your solution to work off your APRN credentials is a smart one. I wish I could do the same as a PHarmD!!
  2. Apr 28, 2012

    Visit our website because our business model for delivering diabetes education (DSMT) is showing much promise. See the "About Us" tab at: www.takebettercareofyourselfkc.com
  3. Apr 26, 2012

    Thank you for the great advice. This is what I've learned so far, Texas Health Springs, a Medicare Advantage Plan, requires a referral to ourselves to get prior authorization to provide DSME. Since we have provided DSME without asking for authorization, we were denied payment. I have now started submitting a referral for pre-authorization and have gotten our request approved.
  4. Apr 23, 2012

    Kit, No I don't have an RD but I think I'm going to have to hire one. I did not know MNT pays better than using the G codes. I will definitely consider hiring a contract dietician. Thank you for the advice. Janice, what is the "average" charge for private pay patients? A physician referral is still needed for DSME/T but we have a physician will refer the patient if the patient does not have a primary care provider. Jane, yes it is discouraging at times.
  5. Apr 23, 2012

    Are you kidding. It is incredible! I have had so many issues with Medicare and other HMO's. I am about the only educator in my area still doing DSMT . I am in a pharmacy and all my other educator friends have quit. This is so sad.
  6. Apr 23, 2012

    I have a hospital based DSMT program. Many patients have a high deductible and, therefore, opt not to come to the program. Can a patient choose not to pay for the program through insurance but to pay the fee that we charge for the "non-insursed" patients? If that is possible, do the patients still need a physician's order?
  7. Apr 20, 2012

    Hi Iris! I'm sorry to hear that you're having reimbursement issues. Do you have a RD on staff? My accredited program does well with reimbursement. We do very few "classes" and choose, instead, to see most patients on an individual basis. We do this for several reasons: 1. We bill and exhaust MNT hours before moving on to G codes. MNT hours are reimbursed significantly better. (Most of our Medicare patients have a private supplemental policy - my dual eligible patients I do lose reimbursement on if billing G codes - the 20% and deductible does NOT apply to MNT.) 2. Many private insurance companies do not recognize G codes. These tend to be Medicare specific. So again, I see patients with private insurance on an individual basis and bill MNT codes. 3. In addition to maximizing revenue, seeing patients individually just yields better results for us. We have tried everything - group classes - changing the time and length of classes - participation is poor. The most important thing that we do is conduct a benefits investigation for every patient that is referred. I know that this is time consuming, but it works for us. And patients appreciate knowing before hand what their co-pay or cost will be. I know we have different demographics. Please let me know if I can help. If you do not have a RD on staff to bill these MNT hours I hate to say it, but it will be difficult if not impossible to have the program pay for itself (in my humble opinion). Please keep me posted on how it goes!
  8. Apr 20, 2012

    Billing can be very confusing. Often it is a simple fix like changing the name on your certificate to match the NPI number from where you are billing from. Sometimes in a practices such as internal medicine, billers attempt to bill for the instructor not the program or treat it as an “incident-to”, which it is not. If in doubt, AADE members can utilize AADE’s reimbursement expert for their questions. Here is an example of a question asked during one of our recent reimbursement-related webinars: Question from participant: You said we can use the physician that has sponsored the accredited program as the billing provider for DSMT services and that the physician does not need to be on site when the DSMT service is provided. So does that mean that supervision requirements do not apply for DSMT? (Our CDE can use the sponsor MD as the billing provider and they do not have to be in the building?) Answer from the AADE Reimbursement Expert: Correct, supervision requirements or incident-to do not apply to DSMT. Leslie Kolb, Director AADE Diabetes Education Accreditation Program

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