The Real Skinny on Medicare Billing Through an Accredited Diabetes Self- Management Program

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1 The Real Skinny on Medicare Billing Through an Accredited Diabetes Self- Management Program 1

2 Dallas Area Agency on Aging The Dallas Area Agency on Aging (DAAA) is the department under the umbrella of the Community Council of Greater Dallas responsible for planning, advocating, coordinating resources and providing services for seniors (persons 60+) and their caregivers in the Dallas County area. It is part of a national network administered by the Federal Administration on Aging and funded under the Older Americans Act. The Act provides for grants to states, area agencies and local agencies to ensure the needs of seniors are met through the provision of nutrition and other community services. Funds are passed through the Texas Department of Aging and Disability Services, the state s aging organization responsible for contract compliance. 2

3 Better Choices, Better Health-Dallas Classes provide seniors with diabetes self-management strategies for healthier living. Based on Stanford University s widely tested Chronic Disease and Diabetes Self Management Program, the two-and-one-halfhour, seven-week sessions help you understand and take constructive steps to manage your chronic condition in a positive way and with proven results. Better Choices, Better Health Dallas is part of The National Council on Aging Better Choices, Better Health, and is the first community-based program in Texas accredited by the American Association of Diabetes Educators. Classes will help you: Deal with pain, fatigue and stress Discover better nutrition and exercise choices Understand new treatment options Learn better communications with your doctor and your family. 3

4 TIMELINE CDSMP/DSMP Started 2010 Accreditation (AADE) February 2013 Medicare Classes Started March

5 CURRENTLY DSMT Program Coordinator Jessica Walker 10 Master Trainers 30+ Lay Leaders 40+ Classes Provided to Date 10 Medicare Sites 8 DSMT/Medicare Classes 5

6 Sustainability of EB Programs Timothy P. McNeill, RN, MPH

7 1 Introduction 2 DSMT Initiative 3 Business Acumen TA 4 Managed Care Contracting

8 Introduction ACL/AoA has embraced the adoption of evidence-based (EB) programs ARRA and Older Americans Act funding supported expansion of EB programs

9 Sustainability Consulting services for AoA/ACL to develop models of sustainability for EB Programs Funding supports expansion of EB programs and support the growing demand for these services

10 Sustainability Plan ACL/AoA launched a four year initiative to develop the infrastructure to develop sustainable models of DSMP delivery Toolkit developed Sample Business Model Targeted TA Expansion to other Network sites 10

11 Stanford DSMP Program site analysis Initially conducted an analysis of each DSMP program site Infrastructure Staffing mix Delivery model Target population Integration with the health care delivery system

12 Recommendation Developed a hypothetical model Anywhere AAA Partner DSMP program with Medicare provider partner Supplement infrastructure to meet National Accreditation and Medicare billing guidelines Develop break-even analysis Provide revenue projection model

13 Sustainability Consulting ACL/AoA initial tasks included the following Develop a hypothetical model for sustaining EB program using Medicare reimbursement Assess 15 programs currently conducting programs Identify 5 and provide intensive TA Dallas AAA was one of the original 5 selected sites under this initiative

14 Market Analysis Market Analysis is a critical component to sustainability Identify the Payer landscape Market Penetration of payers State climate for reform State level initiatives

15 Initiative Status Five programs fully accredited by the American Association of Diabetes Educators and recognized by Medicare Two programs with pending applications for accreditation Two programs beginning the accreditation process There are other programs that have sought and achieved accreditation. This slide represents the programs that I have supported under the ACL/AoA consulting contract 15

16 Path to Reimbursement A program must first attain accreditation Accreditation requires the program to demonstrate that their program provides diabetes self-management education according to the ten (10) National Standards Once Accreditation is achieved, the program must submit for Medicare recognition Programs that have accreditation and recognition are eligible to receive reimbursement from Medicare 16

17 CMS Approved Accrediting Organizations American Diabetes Association (ADA) American Association of Diabetes Educators (AADE) March 2009 Accreditation process, for both organizations, is based upon the National Standards for Diabetes Self- Management Education (DSME) 17

18 Program Considerations (Cont.) As a Part B services, beneficiaries without Part B cannot receive the service paid for by Medicare Part B Beneficiaries that have elected Medicare Part C (Medicare Advantage) must receive their benefit from a Medicare Advantage approved provider Medicare recognized programs can contract directly with a Part C plan provider to provide these services Once approved by Medicare, negotiate directly with the dominant Medicare Advantage Plan in your market 18

19 History of DSMT Benefit The Centers for Medicare & Medicaid Services (CMS) provides reimbursement for DSMT Benefit began in 2002 Benefit provides compensation for up to ten (10) hrs of DSMT per 12 month period All recognized Medicare providers can submit for reimbursement Medicare coverage 80% Payment 20% Co-insurance required 19

20 Hours of Training Covered Ten hours of training are covered in the first year 1 hour of individual training 9 hours of group training Lifetime benefit Coverage during the 12 month period after the start of the service based on a provider order Follow-up training is available to beneficiaries after the initial 10 hours Beneficiary must have a diagnosis of diabetes Pre-diabetes or high-risk for diabetes does not meet the qualification Two part process to be eligible for reimbursement Accreditation Recognition 20

21 Partnership A Significant barrier can be establishing a partnership with a Medicare Provider One program can have more than one partner Relationship must be mutually beneficial If the negotiations are difficult in the beginning, they will likely remain difficult for the duration of the relationship Both organizations must have a process to track and monitor services Class participants Services delivered Timely filing of claims Claims reconciliation Revenue sharing 21

22 Types of Partners Management Service Organization (MSO) Hospitals Health Departments Patient-Centered Medical Homes Private Practice Doctors or Group Practices FQHCs Rural Health Clinics 22

23 Disease Self-Management in the market More and more payors are realizing that disease management is essential to lowering costs Many national insurers such as United Healthcare, Centene Corp (Medicaid MCO), Amerigroup (Medicaid MCO) and others are beginning to provide financial incentives to the patient for completing disease selfmanagement education Medicare will be doing a demonstration to provide an incentive to beneficiaries that complete disease selfmanagement education PCMHs and ACOs focus is on lowering costs for persons with chronic disease. Disease self-management is required 23

24 Opportunity Identify the types of insurers in your area Investigate to see if they cover disease selfmanagement education and training Review how to become a provider under this plan Accreditation provides leverage in the negotiation You should know how to price your service before beginning negotiations 24

25 CMS Medicare Data At the following link, CMS provides monthly Medicare enrollment data: https://www.cms.gov/mcradvpartdenroldata/01 _Overview.asp#TopOfPage Once at this page you can make a quick assessment of the numbers in your area by reviewing the Medicare Advantage Penetration Table. State_County_Penetration_MA 25

26 Business Acumen TA Initiative May 2013, ACL launched a learning collaborative to provide expanded TA to networks of community-based aging and disability organizations (CBOs) to improve their Business Acumen

27 Business Acumen Learning Collaborative Collaborative is supported by a team of ACL staff, contractors, and grantees 9 networks of CBOs selected across the U.S. Texas Coalition is one of the grantees for this initiative Supports continued assistance to the Dallas AAA

28 Business Acumen Goals Provide targeted TA to selected sites Support their local efforts to secure at least one contract with an integrated care organization Accountable Care Organizations (ACOs) Medicaid Managed Care Organizations (MCOs) Medicare Advantage

29 Managed Care landscape Important to understand the market forces for managed care: Medical Loss Ratio PMPM (Per Member Per Month) Premium Payments NCQA Credentialing Standards

30 Strategy Development Identify the local market drivers Assess the landscape of health reform initiatives Understand the political landscape Develop a strategy Implement the strategy

31 Questions Questions can be submitted in this open forum or by Timothy P. McNeill, RN, MPH Consultant Direct: (202)

32 After Accreditation Reaffirming/Confirming Sites Marketing Program/Recruitment of Targeted Population Collection of Physician Referrals Train Lay Leaders Meet with Medicare Provider/PQI to Discuss Program Logistics and HIPPA Guidelines Meet with Advisory Board to Review Quality Improvement Plan Develop Calendar of Classes 32

33 Challenges PQI and Lay Leader Scheduling PQI/RN Being at Multiple Locations Maintaining Participant Files Data Collection Not Knowing Who Qualifies for MNT or DSMT in Advance of Class Timely Submission of Billing Funds for Program Material and Volunteer Stipends Inadequate number of Master Trainers/Lay Leaders proficient in the Spanish curriculum 33

34 More Challenges and Pitfalls Medicare Provider/Need to Identify Another Medicare Provider Not Having Access to Actual Bill Submitted to Medicare Community Sites 34

35 Lessons Learned Need to Start Small (fewer sites ) Select the Right Medicare Provider the First Time Clearly Clarify Roles (Medicare Provider, Lead Agency, PQI, Lay Leader, Sites, etc.) Don t Expect the Big Bucks to Roll in all at Once MNT Must be a Part of the Service Delivery Consider Getting a Medicare Provider Number 35

36 Program Successes!!! Approximately 78 Persons Completed Medicare Classes Successfully Billed Approximately 20 to 30 persons Received Approximately $ Reimbursement for DSMT Training A Successful AADE Annual Report Showed that Approximated 67% of our Participants had A1Cs and Daily Blood Glucose Monitoring and 100% of Participants were Involved in a Daily or Weekly Exercise Program after the Class a Year Later. Mini Grants 36

37 Contact Information Merida Millie DeAnda, Director Jessica Walker, Program Manager Dallas Area Agency on Aging 1349 Empire Central, Suite 400 Dallas, TX (214) (214) fax betterchoicesdallas.org 37

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