Diabetes Self-Management Training Accreditation and Medicare Reimbursement Frequently Asked Questions

Transcription

1 Last updated 1/9/2014 Diabetes Self-Management Training Accreditation and Medicare Reimbursement Frequently Asked Questions This document includes questions asked during a National Council on Aging webinar, Obtaining Diabetes Self-Management Accreditation and Medicare Reimbursement: What States Need to Know, conducted on February 8, 2013, plus some other questions raised recently by AoA grantees. We will update this document as we receive additional questions. Accreditation Questions Reimbursement/Billing Questions State Roles Miscellaneous Questions For More Help Where to Submit Additional Questions Accreditation Questions 1. What is the average time it takes for AAAs (Area Agencies on Aging) to go through the entire process of Diabetes Self-Management Training (DSMT) accreditation? 2. To date (February 2013), how many organizations have attained accreditation and are being reimbursed for delivering DSMP? 3. Does the Stanford model Diabetes Self-Management Program meet the accreditation standards required for Medicare reimbursement as is? 4. Can we add the needed infrastructure elements to the Stanford model DSMP without violating fidelity to the Stanford program? 5. Is the Stanford Diabetes Self-Management Program (DSMP) model the only type of program that can achieve accreditation? 6. Can a program that uses lay leaders still meet the ten National Standards for accreditation of diabetes programs? 7. Are the ten National Standards for accreditation of diabetes programs that were approved in 2007 still valid? 8. Can we still provide DSMP workshops without seeking accreditation? 9. Can our American Association of Diabetes Educators (AADE) accreditation cover more than one site? 1

2 Reimbursement/Billing Questions 1. Medicare benefits cannot include incentives to increase use of the service. Can participants receive the book that accompanies the DSMP (Diabetes Self-Management Program) workshop? 2. About how long does it take to get a Medicare number (to be a Medicare provider), not counting anything DSMT-specific? 3. Can a group of providers get a Medicare number together? 4. If a Medicare provider partner is already billing for other diabetes services, can they also bill for DSMT (Diabetes Self-Management Training)? 5. I was told that CMS does not reimburse for DSMT programs accredited by the American Association of Diabetes Educators (AADE), only programs accredited by the American Diabetes Association (ADA). Is this accurate? 6. Is there a limit on the number of units billable on a particular day for one beneficiary? 7. Which beneficiaries are eligible for the DSMT and how many hours are they eligible to receive? 8. Do you have any advice on how to partner with private insurance carriers? 9. Can any Medicare provider bill for DSMT? 10. If we are a Medicare provider, can we bill Medicare only for DSMT? 11. Who is liable for the delivery of DSMT and what happens if Medicare is fraudulently billed for the service? 12. Many Medicare beneficiaries in my community are in Medicare Advantage plans or enrolled in an Accountable Care Organization (ACO). Should I still consider pursuing DSMT classes for Medicare beneficiaries? 13. How can I find out how many Medicare beneficiaries are in my specific market? 14. There are already DSMT programs in my community so haven t they already helped everyone who needs DSMT? 15. Does Medicare reimburse for CDSMP? State Roles 1. What is the states role, specific to the accreditation process? 2. Can states be helpful in guiding local AAAs regarding training, counseling, etc.? Miscellaneous Questions 2 1. Where can I get enough referrals to keep my program running?

3 2. Does Medical Nutrition Therapy (MNT) require accreditation? 3. We ve provided DSMT for many years. We ve never provided MNT. Where do we start? 4. Will our participants who receive Medical nutrition therapy (MNT) services have to pay out-of-pocket expenses? 5. Where can I find documentation that the Centers for Medicare & Medicaid Services (CMS) recognizes the American Association of Diabetes Educators (AADE) as a national accrediting organization? For More Help Where to Submit Additional Questions Accreditation Questions 3 1. What is the average time it takes for AAAs (Area Agencies on Aging) to go through the entire process of Diabetes Self-Management Training (DSMT) accreditation? There is considerable variation in the timing of the process. While certain aspects are standardized (e.g., the time it takes to deliver your pilot workshop), others are not. Here are some considerations that affect the timing: Find and negotiate with a Medicare provider or apply and receive approval to be your own Medicare provider. You control the timing for most of this step. Review the accreditation standards and ensure that you can provide the proper infrastructure. You control the timing for this step. Next, deliver the Diabetes Self-Management Program (DSMP) workshop according to the standards, with the required wraparound structure. That takes 8 weeks. It will likely take another two weeks for you to complete the application for accreditation, although you may be able to complete it while the workshop is taking place. You will then need to submit your application to your choice of either the American Association of Diabetes Educators (AADE) or the American Diabetes Association (ADA). They take approximately two weeks to review the application. Upon completion of the review, the accrediting organization you chose (AADE or ADA) will schedule a site visit or telephone interview. Your availability will determine the timing on this step.

4 At the end of the site visit or telephone interview, the accrediting organization will indicate whether or not you will be accredited. It generally takes another week to receive the certificate of accreditation. Upon receipt of the accreditation certificate, the Medicare provider must submit a copy of it to their Medicare Administration Contractor (MAC) as proof of completion of the accreditation standards. The provider will then be formally recognized by Medicare as an approved provider of DSMT. While the full process as described above can conceivably take about 12 weeks in a perfect world, you should plan for a longer process in case of delays (e.g., you may not have a DSMP workshop scheduled in the immediate future, it may take a considerable amount of time to secure and negotiate with a Medicare billing partner, it might take a while to identify necessary staff, etc.). 2. To date (February 2013), how many organizations have attained accreditation and are being reimbursed for delivering DSMP? Five organizations have successfully achieved accreditation, with two receiving reimbursement and one very close to receiving it. For two others, Medicare recognition will be retroactive to the date they achieved accreditation and submitted proof of their accreditation. 3. Does the Stanford model Diabetes Self-Management Program meet the accreditation standards required for Medicare reimbursement as is? No. The Stanford model does not have the following elements required to meet the ten National Standards for accreditation: Advisory group to promote quality DSME instructors to have regular continuing education and have one that is at least an RN, RD, or RPH/PharmD Individual assessment and education plan, developed by the primary qualified instructor Personalized follow-up plan Continuous quality improvement However, the Stanford model can be the main curriculum within a larger infrastructure that includes all of the elements above. When packaged in that way, a program that uses the Stanford model can achieve accreditation. 4

5 4. Can we add the needed infrastructure elements to the Stanford model DSMP without violating fidelity to the Stanford program? Yes. The additional infrastructure that you are adding to support the Stanford DSMP model are meant to meet the ten (10) National Standards of Diabetes Self-Management Education. However, these infrastructure elements are provided around the Stanford workshop in a manner that allows the Stanford Model to adhere to fidelity requirements. The combined approach of the Stanford Model with supporting infrastructure allows the program to pass accreditation and seek reimbursement. As with any licensed Stanford model program, you may still use lay leaders and follow the entire 6-week Stanford curriculum and, with the additional infrastructure, be in compliance with the accreditation standards. The other requirements to meet the standards are added before and after the workshop series, in a manner that does not negatively impact program fidelity. 5. Is the Stanford Diabetes Self-Management Program (DSMP) model the only type of program that can achieve accreditation? No. Stanford DSMP is one example of an evidence-based model that has successfully met the national accreditation standards when implemented along with a supporting infrastructure. 6. Can a program that uses lay leaders still meet the ten National Standards for accreditation of diabetes programs? Yes. Standard 5 - Instructional Staff (page 3) of the 2012 updated Standards highlights and reaffirms the role and use of lay leaders or community health workers in the delivery of diabetes self-management education. The update clearly explains that lay health workers can contribute to diabetes self-management instruction and can play an important role in the process. The last two paragraphs of the Standard 5 section are focused on the role of lay health leaders in the process. 7. Are the ten National Standards for accreditation of diabetes programs that were approved in 2007 still valid? No. The only currently valid version was approved in 2012 Previous versions (including the 2007 standards) are not usable. 8. Can we still provide DSMP workshops without seeking accreditation? Yes. Going through the accreditation process and partnering with a Medicare provider gives you the opportunity to help sustain your workshops but accreditation is not a requirement for AoA grantees. 5

6 9. Can our American Association of Diabetes Educators (AADE) accreditation cover more than one site? Yes. AADE now allows each accredited entity to have up to 10 regularly visited community sites within the same state. The community sites must offer the same program as the main location and are simply an extended copy of the accredited diabetes education program. All billing for these services must go through the main location. AADE does not post the community sites on their website and the sites do not receive a separate certificate. For additional information, please visit the AADE Website and click on the link to Community Sites". Reimbursement/Billing Questions 1. Medicare benefits cannot include incentives to increase use of the service. Can participants receive the book that accompanies the DSMP (Diabetes Self-Management Program) workshop? Yes. The books are not considered incentives. Programs are required to provide diabetes selfmanagement support materials to participants as an essential part of the education process. 2. About how long does it take to get a Medicare number (to be a Medicare provider), not counting anything DSMT-specific? It takes anywhere from about 3-6 months to get a Medicare number. 3. Can a group of providers get a Medicare number together? There are no group numbers. However, a provider can have multiple locations. For example, an IPA of AAAs can have multiple locations that serve each of the AAAs. The IPA can have one provider number to serve the community of AAAs that are part of the IPA. Each of those AAAs in the IPA would not need its own Medicare provider number. 4. If a Medicare provider partner is already billing for other diabetes services, can they also bill for DSMT (Diabetes Self-Management Training)? Yes. As long as the DSMT service is provided by an accredited program and by a provider that is recognized by Medicare, it can be delivered along with any other service needed by the beneficiary. 6

7 5. I was told that CMS does not reimburse for DSMT programs accredited by the American Association of Diabetes Educators (AADE), only programs accredited by the American Diabetes Association (ADA). Is this accurate? No, that is not accurate. At one point ADA was the only entity eligible to provide accreditation for programs that wanted to seek Medicare recognition. However, this was changed in 2009 to include the American Association of Diabetes Educators (AADE) as an approved National Accrediting Organization. Every Medicare Administrative Contractor must honor successful completion of accreditation by either entity AADE or ADA. 6. Is there a limit on the number of units billable on a particular day for one beneficiary? No. However, while there is no limit, you may target yourself for an audit if, for example, a beneficiary gets 10 hours of education in one day. Also, DSMT and MNT (Medical Nutrition Therapy) cannot be billed on the same day. In addition, there are specific rules applicable ONLY to Federally Qualified Health Centers (FQHCs) that put limits on the number of billable services that can be provided each day. 7. Which beneficiaries are eligible for the DSMT and how many hours are they eligible to receive? Beneficiaries must have a diagnosis of diabetes and be enrolled in Medicare Part B. For beneficiaries with a diabetes diagnosis who have Part C, the Medicare provider must establish an agreement with the applicable Advantage Plan administrator. CMS provides reimbursement for up to 10 hours of DSMT during the initial 12 month period following submission of the first claim for this benefit. CMS will also reimburse for follow-up training provided to eligible beneficiaries after they have received the initial 10 hours. The follow-up training is 2 hours and is available every calendar year after the first year that the beneficiary uses their initial benefit (10 hours) as long as the beneficiary continues to have a diagnosis of diabetes. NOTE: This means that a beneficiary can only use that initial 10 hour benefit once. The follow-up 2 hour benefit can be used every year thereafter. 8. Do you have any advice on how to partner with private insurance carriers? All insurance plans, including Medicare Advantage plans, are graded according to Healthcare Effectiveness Data and Information Set (HEDIS) measures, which are heavily weighted towards diabetes outcomes, so it is good for the plans to offer diabetes education because it is proven that beneficiaries that attend accredited diabetes education programs have improved health outcomes and lower costs of care. Having an accredited program demonstrates that you are a strong partner, making it easier to negotiate to become a network provider for the managed care plan. You should highlight your reach, as well as your ability to meet national standards for provision in community settings. 7

8 9. Can any Medicare provider bill for DSMT? Yes, if they meet all the requirements, with one caveat. Medicare providers that only bill Medicare for Durable Medical Equipment (DME) can bill for DSMT, but they must take additional steps with Medicare provider enrollment before they can bill for DSMT services. There is specific guidance in the CMS policy manual that provides direction for DME providers that wish to begin billing for DSMT. The guidance can be found in the CMS Medicare Benefit Policy Manual, Chapter 15 - covered Medical and Other Health Services. Please reference section titled "Certified Providers." This section outlines the regulations describing how to become a DSMT provider. This section was made effective 3/30/2009 with full implementation of the policy effective 9/8/2009. Pay particular attention to the subheading titled, "Enrollment of DMEPOS Suppliers." 10. If we are a Medicare provider, can we bill Medicare only for DSMT? No, DSMT cannot be the only service billed to Medicare. However, Medical Nutrition Therapy (MNT), for example, which is often offered in conjunction with DSMT, can be the primary service, with DSMT billed as a secondary service. (NOTE: MNT must be delivered by a registered dietitian). 11. Who is liable for the delivery of DSMT and what happens if Medicare is fraudulently billed for the service? You and the Medicare provider are liable for the delivery of DSMT. Therefore, if fraudulent billing occurs for services that were not rendered, you would be liable for the fraud that occurred. To ensure against this, we recommend that you jointly participate in the delivery of these services. If the concern is regarding malpractice, this is a health education program that is done under referral from the patients primary care physician so there is limited malpractice risk. 12. Many Medicare beneficiaries in my community are in Medicare Advantage plans or enrolled in an Accountable Care Organization (ACO). Should I still consider pursuing DSMT classes for Medicare beneficiaries? Yes. Even in markets that are considered to have high Medicare Advantage enrollment, such as San Diego and South Florida, 50% or more of their Medicare beneficiaries are NOT in Advantage plans. There are also potential possibilities for contracting directly with Medicare Advantage plans to provide DSMT to their enrollees. ACO participation mandates that the beneficiary not be enrolled in a Medicare Advantage plan. When 8

9 the panel of patients is assigned to an ACO, all Medicare Advantage patients are excluded from their patient count. In addition, ACOs are prohibited from applying limits on service utilization by their ACO patients. Lastly, the DSMT service is complementary to the goals of the ACO program. ACOs are expected to be successful by expanding access to preventive health services for their population of ACO patients. In other words, no matter where you are located, there are still plenty of Medicare beneficiaries with a diagnosis of diabetes who can benefit from self-management education. 13. How can I find out how many Medicare beneficiaries are in my specific market? CMS provides monthly Medicare enrollment data. 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 You will be prompted to download a file that has the current Medicare and Medicare Advantage enrollment to the County level for every State and Territory in the United States. You can then look up the statistics relevant to your area. 14. There are already DSMT programs in my community so haven t they already helped everyone who needs DSMT? No. DSMT is one of the most under-utilized Medicare benefits. According to AADE s analysis of CMS recent claims data (2012), only 1.5% of eligible Medicare beneficiaries with a diagnosis of diabetes have used their DSMT benefit. Clinical models of DSMT and community-based models can co-exist in communities. It will take the synergistic efforts of both models to reach the 98.5% of the Medicare population that is not using this essential benefit currently. 15. Does Medicare reimburse for CDSMP? No, currently Medicare does not reimburse for CDSMP. State Roles 1. What is the states role, specific to the accreditation process? Community Based Organizations (CBOs) may experience challenges in identifying and negotiating a mutually beneficial relationship with a Medicare billing partner, and the support of the state unit on aging and/or health department can be very important. States can also provide information regarding local resources for program referrals. Medicaid Managed Care 9

10 (MCO) plans pay close attention to what states want and are inclined to please the states, so when the CBO approaches an MCO plan, they may want to have a discussion about the importance of diabetes education to the state. 2. Can states be helpful in guiding local AAAs regarding training, counseling, etc.? Yes. States can encourage a group, team, or coalition of AAA partners or contract agencies to collaborate to provide more services, learn from each other, and leverage strengths/weaknesses. As a group, they can approach Medicare Advantage plans and MCOs and will be seen as stronger and more appealing as a collective entity rather than a single organization. Miscellaneous Questions Where can I get enough referrals to keep my program running? Referrals for DSMT will come from multiple sources. Local physicians, hospitals, and the local health department are important resources. In addition, community-based sites can serve as an important referral source. Community-based programs serving older adults will likely have significant numbers of Medicare beneficiaries with a diagnosis of diabetes. When identified, these persons could be enrolled in a DSMT class. The program staff should inform the person s physician that the individual would like to take the DSMT class and request a referral, which is required. The process of requesting a referral for a requested service is a common practice in Medicare. Medical equipment providers and home health agencies use this approach frequently. When a person requests medical equipment such as a motorized wheelchair, the medical equipment company notifies the physician directly and then requests an order so that Medicare will reimburse for the service. 2. Does Medical Nutrition Therapy (MNT) require accreditation? No. MNT does not require an accreditation process. MNT is a professional service provided by a registered dietitian (RD). Dieticians can use lay leaders to support the delivery of MNT under their supervision. Any licensed RD who is associated with a Medicare provider can provide and bill for the delivery of MNT to eligible Medicare beneficiaries. 3. We ve provided DSMT for many years. We ve never provided MNT. Where do we start? In order to provide MNT, you must have a registered dietitian who is associated with your

11 program. Only an RD is approved to provide MNT services. An RD can use lay leaders and other support staff to assist in the delivery of MNT, as long as there is appropriate supervision by the RD. The focus of MNT is on the impact of nutritional intake on the management of diabetes. In addition, DSMT has always had a component that focuses on nutritional education. In the Stanford Model of DSMP, class two has significant detail on the management of diabetes. When provided under the direction of a registered dietitian, class two meets the requirements of Medical Nutrition Therapy, as long as there is appropriate infrastructure in place to support the MNT service delivery. 4. Will our participants who receive Medical Nutrition Therapy (MNT) services have to pay out-of-pocket expenses? The Affordable Care Act waives the deductible and coinsurance/copayment for certain Medicare-covered preventive services, including MNT services. See the CMS Transmittal. 5. Where can I find documentation that the Centers for Medicare & Medicaid Services (CMS) recognizes the American Association of Diabetes Educators (AADE) as a national accrediting organization? See the CMS Transmittal formally stating that AADE is a National Accrediting Organization for DSMT and must be recognized by all CMS contractors. For More Help Congratulations to you and your partners for your interest in diabetes self-management program accreditation and reimbursement! Besides reading these FAQs, here are some other suggested next steps and resources: First, we suggest that you get a general overview of the process by watching each of the following three webinars. You may not be able to follow all of the information at first, and that s ok. Just watch to get a general sense of the process. The model that we have been supporting provides DSMT along with medical nutrition therapy (MNT) to produce a sustainable program that can qualify for accreditation and eventual Medicare reimbursement. Diabetes Self-Management Training The Ins and Outs of Selling EBPs [Evidence-Based Programs] to Health Care 11

12 Obtaining Diabetes Self-Management Accreditation and Medicare Reimbursement: What States Need to Know Next, set aside a few hours and carefully read the AoA DSMT Toolkit, from start to finish. You may want to go back to some of the sections, to put some of the video information into perspective. At this point, we strongly recommend that you take a step back and talk with the key personnel and decision-makers at your organization and determine whether there is still a strong commitment to proceed in this process. This is not a simple process and it takes time and commitment. You need to have a champion who will support the project from start to finish. If your organization is not already billing Medicare for Part B services, you will need to decide whether you will pursue Medicare provider status and recognition, or partner with an outside organization that is already a current Medicare provider. Negotiating with and working closely with another organization is an art that should not be taken lightly. There are usually some points of disagreement in process or values along the way that can be resolved, but may require some give and take. You will need your organization s strong commitment to get through those issues. Once you know that your organization definitely wants to continue and support this process, you may want to consider hiring someone to help your organization through the process. ACL is not in a position currently to provide one-on-one direct assistance to individual organizations wishing to pursue Medicare reimbursement for DSMT services. However, we are committed to providing general information, samples, suggestions, webinars, etc., to assist you. We are also posting additional process aids on our website as we identify the need for them, so check back frequently to see what s new or ask us to post something specific. Where to Submit Additional Questions If you have specific questions that are not addressed in the webinars, DSMT toolkit or FAQs, please them to Laura Lawrence laura.lawrence@acl.hhs.gov and Michele Boutaugh at michele.boutaugh@acl.hhs.gov. We may not be able to answer directly using information specific to your situation, but we will update the FAQs to address your questions if possible. We thank you for your interest in increasing access to and sustaining this important program for the growing number of people with diabetes. 12