The Comprehensive Guide To Navigating Insurance Billing As A Dietitian

Billing insurance as a dietitian can be a complex process, but it can be made easier with some guidance and persistence. The first step is to decide whether to accept insurance or not. There are pros and cons to both options. Accepting insurance can lead to practice growth, as it increases the number of potential clients and makes services more accessible to those who otherwise couldn't afford them. However, setting up insurance billing can be time-consuming and complex, and insurance companies will set the reimbursement rates.

If you decide to accept insurance, there are several steps to take. You'll need to get an Employer Identification Number, a license (if required in your state), liability insurance, and a National Provider Identifier (NPI). You'll also need to decide which insurance companies to work with and register with the Council for Affordable Quality Healthcare (CAQH). The next steps are credentialing and contracting, which involve becoming an in-network provider and setting reimbursement rates and policies. Finally, you'll need to learn how to submit claims for reimbursement and manage billing. This can be done independently or by hiring a third-party billing company.

How to become an in-network provider

Becoming an in-network provider is a lengthy process that can take several months to complete. Here is a step-by-step guide on how to become an in-network provider as a dietitian:

Get Familiar with State Licensure Laws:

Licensure requirements vary from state to state. While some states may not require any specific education or credentials to practice as a dietitian, others may mandate licensing by the state. It is important to research the laws and requirements specific to your state before initiating the process of becoming an in-network provider.

File as an LLC or S-Corp:

Filing as a Limited Liability Corporation (LLC) or a Subchapter Corporation (S-Corp) has legal and tax implications. It creates a separation between you and your business, offering protection for your personal assets in the event of litigation. Consult with an attorney and an accountant to determine which filing status is most suitable for your practice.

Obtain Liability Insurance:

Liability insurance is essential to protect yourself from potential lawsuits arising from your nutrition counselling services. Most insurance companies require liability insurance, and it is crucial to choose a plan that covers all the services you provide and the states in which you practice.

Get Your National Provider Identity (NPI) Number:

The NPI number is a unique 10-digit identification code that is required when filing insurance claims. The Health Insurance Portability and Accountability Act (HIPAA) mandates that you have an NPI to identify your practice in insurance claims. The application process for obtaining an NPI is straightforward and free, with a turnaround time of 1-20 days.

Decide Which Insurance Companies to Work With:

Research and select a few insurance companies that align with your target clientele, region, and practice goals. Consider reaching out to current clients, referral partners, and peers to understand which insurance companies they work with. You can also check the websites of other dietitians or nutrition professionals in your area to get an idea of the popular insurance providers in your field.

Apply to Be an In-Network Provider:

Each insurance company will have its own application process, forms, and requirements. You can usually find the necessary information and applications on the insurance company's website. Be prepared to provide documentation related to your education, training, experience, and competency as part of the credentialing process.

Start the Contracting Process:

Once you are credentialed, the contracting phase will involve setting your reimbursement rates and policies for filing claims for plan members. This process can vary significantly, taking anywhere from one to six months to complete. It is important to be persistent, follow up with the insurance company, and stay organized throughout this phase.

Becoming an in-network provider as a dietitian requires a significant amount of time and effort. However, by following these steps and staying committed to the process, you will be well on your way to establishing yourself as an in-network provider.

The pros and cons of accepting insurance

There are several reasons why a dietitian may or may not want to accept insurance. Here is a list of advantages and disadvantages to help dietitians decide whether to accept insurance or not.

Pros

• Reach more people with your services: When you accept insurance, you open up opportunities to patients who can consume your services. This is especially beneficial if you practice in an area with lower incomes.
• Bill as preventative services: The Affordable Care Act (ACA) allows dietitians to bill for preventative services. These services are often tied to interventions that decrease the risk of mortality and morbidity associated with cardiovascular disease. When billed correctly, the patient pays nothing for these services and can generally see the dietitian as often as needed.
• Build a network of people that refer you patients: Doctors are more likely to refer their patients to in-network dietitians. This can be an easy handoff when you accept insurance, especially the same insurance that they accept.
• Solid pay: Reimbursement rates for dietitians are solid and most dietitians accepting insurance are making well above $100 per hour, with some states paying double that.
• You can bill for any program or service: Dietitians can bill for high-ticket packages and a la carte services like body fat testing and metabolism testing.

Cons

• Learning curve: There is a big learning curve when it comes to accepting insurance and billing. It is not taught in school and dietitians may need a mentor or coaching program to guide them through the process.
• Billing is not universal: Each insurance company is a little different when it comes to billing. Dietitians need to practice and learn the fundamentals of billing for each major insurance company.
• Not all networks are open: Some insurance companies may inform you that their network is closed to new providers, which can be frustrating.
• Better coverage for certain conditions: There is better coverage for certain conditions such as weight management, prediabetes, metabolic syndrome, and CVD. However, other conditions like celiac disease, IBS, IBD, and lactose intolerance are considered medical conditions and may require a cost share from the patient.
• Time-consuming: The process of getting set up to accept insurance can be time-consuming and may take months to complete. It involves getting an NPI number, legally registering your practice, and setting up a system for processing insurance billing.
• Filing insurance claims can be complicated: Filing insurance claims requires filling out CMS 1500 forms correctly and tracking which claims have been processed and which ones are still pending.
• Boxed-in rates: When you start taking insurance, you may get boxed-in rates set by the insurance company, which can limit how much you are able to charge for your services.

In conclusion, there are both advantages and disadvantages to accepting insurance as a dietitian. Dietitians should carefully consider their long-term goals and how accepting insurance could impact their business before making a decision.

Credentialing and contracting

Credentialing

Credentialing is the process by which insurance companies verify that a dietitian is in good standing. This is done via the Council for Affordable Quality Healthcare (CAQH). The CAQH ProView Portal securely stores your information as a healthcare provider. Once you enter your information into the portal, you can authorise specific plans to access your information for credentialing. The CAQH serves as a digital filing cabinet where you can securely store your information as a provider.

To become credentialed, you will need:

• An Employer Identification Number
• A license (if required in your state)
• A National Provider Identifier (NPI)
• Liability insurance

Contracting

Contracting is the process of becoming an in-network provider with insurance companies. This is where you get a contract that sets your reimbursement rate with each individual insurance company. It also establishes the policies and guidelines for filing claims for plan members. It is recommended that you apply to several carriers at once, as processing times vary.

The process of filing a claim

• Eligibility Checks: Before your initial consultation with a new client, it is crucial to verify their insurance coverage for your wellness services. This can be done by calling the insurance provider or using online benefits verification tools. This step also includes obtaining information such as copay and deductible amounts.
• Create a CMS 1500 Claim: After your consultation, you will need to create a CMS 1500 claim, which is a standard form used to submit services for reimbursement. The form requires client personal information, billing information, referral information (if required), your provider information, practice information, insurance policy information, and diagnosis codes (CPT and ICD-10).
• Scrub CMS 1500 Claim: Review your claim for accuracy to avoid denials and delays. If using a clearinghouse, claims will be automatically scrubbed, but if done manually, ensure the form is complete and the correct codes are used.
• Submit the CMS 1500 Claim: Submit the claim electronically through the insurance company's portal, a clearinghouse, or by mail. If in-network with multiple insurance payers, you may need to use a combination of these options.
• Claim Processing and Follow-up: It typically takes a few weeks for the insurance payer to process the claim. If approved, review the reimbursement details and ensure the amount matches your contract rate. For denied claims, determine the reason for denial and make any necessary adjustments before resubmitting.
• Accounts Receivable: For any client-owed amounts, such as copays or deductibles, collect payment or keep a credit card on file to charge these balances. This step can be time-consuming and may require sending invoices or receipts to clients.

The entire process can be handled by a third-party billing company, which can save time and improve accuracy. Alternatively, you can manage billing in-house, especially if you have a smaller client load. Remember to stay patient during the process and don't hesitate to seek guidance from peers or mentors who have navigated insurance billing before.

When to hire a third-party insurance biller

Hiring a third-party insurance biller can be a great option for dietitians who want to streamline their billing process and focus on providing client care. Here are some factors to consider when deciding if and when to hire a third-party insurance biller:

• Client Load and Time Management: As your client load increases, managing insurance billing can become time-consuming. Hiring a third-party biller can free up your time, allowing you to focus on revenue-generating services and business growth.
• Specialization and Expertise: Third-party billers who specialize in dietetic and health coaching claims stay up-to-date with changes in ICD-10/CPT codes and industry best practices. This enhanced specialization can lead to improved accuracy in billing and higher success rates.
• Accuracy and Efficiency: Third-party billers handle a high volume of claims and are experts in completing them correctly. Their expertise can reduce the rate of denied claims and save you time and effort in reprocessing.
• Financial Considerations: Hiring a third-party biller typically involves a cost, often a percentage of successful claims. Consider your client load and whether the benefits of hiring a biller outweigh the cost. If you have a smaller client load, you may want to manage billing in-house initially and hire a biller as your business grows.
• Mental Load and Stress: Billing can be a daunting and stressful task, especially if you feel unprepared or overwhelmed. Outsourcing billing can reduce your mental load and allow you to focus on your passion for working with clients.
• Number of Claims: If you process a moderate to high number of claims weekly (approximately 10-25), hiring a third-party biller may be more efficient and cost-effective than managing billing in-house. Group practices with multiple providers may also benefit from outsourcing billing to streamline the process and reduce errors.
• Staying Up-to-Date: Keeping up with changes in insurance company reimbursements and evolving codes can be challenging for dietitians. Third-party billers specialize in staying abreast of industry updates and can help ensure your claims are coded and submitted correctly.
• Number of Insurance Companies: If you are credentialed with multiple insurance companies, processing claims can become complex and time-consuming. Outsourcing billing to a third-party biller can simplify this process and ensure compliance with different insurance company requirements.
• Credentialing and Contracting: The process of becoming credentialed and contracted with insurance companies can be time-consuming and challenging. Third-party billing companies can manage these processes for you, allowing you to focus on patient care.
• Practice Size and Resources: If you have the resources, hiring an assistant or office administrator to manage billing and other administrative tasks may be an option. However, for smaller practices or those with limited resources, outsourcing to a third-party biller can be more cost-effective and efficient.

Frequently asked questions