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Reimbursement for DSMT is so Low--Is it worth it?

May 26, 2015

The Texas Medical Foundation (TMF) had a very informative and enlightening webinar recently encouraging primary care settings to provide DSMT. I was pleasantly surprised to discover that the Centers for Medicare and Medicaid Services had increased the reimbursement for G0108 (Diabetes outpatient self-management training services, individual each 30 minutes) and G0109 (Diabetes outpatient self-management training services, group session-two persons or more-each 30 minutes) for accredited/recognized programs to $53.32 and $18.10, respectively.

I practice in Texas and Medicaid does not reimburse for DSMT. However, insurances do reimburse and usually follow the Medicare reimbursement rates. Our clinic is considering becoming a DEAP provider now that we have a flow for the Shared Medical Appointments. Several benefits of accreditation/recognition would be the additional revenue generated separate from the medical encounter and the collection and submission of data to track and report outcomes. However, there is no specific billing code for shared medical appointments that I know of. So, one of our concerns is whether the financial reimbursement would be sufficient to cover the cost of hiring a diabetes educator.

While we know DSMT is important and patients should receive it, how can a program remain viable and sustainable when reimbursement is so low? What do you think about the current reimbursement rates? Does your state’s Medicaid program reimburse for DSMT?

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  1. Jun 07, 2011

    I'm in Texas also. I have a DEAP and am in private practice. If overhead is closely monitored, there's no reason a DEAP program cannot sustain a CDE as well as an additional FTE support person (to make appointments and verify benefits). If your CDE is also a RD, you have the advantage of billing for MNT, which has higher reimbursement and allows an additional 3 hours the initial year (2 hours in subsequent years) with a dx of diabetes. This is for Medicare alone. Most private insurance follows suit. However, what we have found is that you MUST call and verify benefits for each and every patient. DSMT/MNT benefits often fall under a deductible or have specific limitations (3 visits per year, etc.). You have to take it on an individual basis and work with insurance to get each patient their maximum benefit. When you do this, you can not only remain viable and sustainable - your program can thrive, as can compensation for providers. I think that most hospital based programs struggle because DSMT is claimed through a centralized billing department and there are no benefits investigations up front. So....you have patients who receive services, their insurance doesn't pay, and the facility must write it off - or they have a co-pay that is not collected at the point of service. It's all lost revenue and inefficiency. I guess, in the grand scheme of things, DSMT reimburses very little compared to other services so large facilities might not take too much notice - but then, that means that they aren't taking too much notice of CDE's either. If you're going to have a program, make it profitable. Make people take notice. That's how you grow a business, get more referrals/patients and, ultimately, make a difference. It can be done!

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