Understanding Insurance Coverage for Nutrition Counseling

Insurance Coverage
and Nutrition Counseling

One of my primary goals as a professional is to make care accessible to people. That is why I choose to be in-network with the local insurance panels that commonly provide coverage for medical nutrition therapy.

But the system is confusing for all of us.

Each insurance company has different practices. And even what is or is not covered within any given company can vary by policy. There can sometimes be limitations to how many visits a person gets per year with a dietitian, what clients are expected to pay, and which diagnoses they will and will not cover and for how long. It can lead to unexpected financial issues for folks. That’s why it is really important to know your policy in advance by contacting your insurance company.

To make it (a little) easier, let’s explore a little more about some of the terminology behind insurance and what you should know if you’re exploring nutrition counseling – whether with me or any other dietitian.

Quick Resources

Insurance Verification Questions

If you want to skip right to verifying your coverage, you can use this script when contacting insurance. This can be used specific to Nourishing Bits and Bites, LLC or for any other dietitian. But to explore other provider, it does matter if the provider is “in network.” Insurance companies use the tax identification number and/or provider NPI of the provider you wish to see.

Referral Form

Folks with a HMO insurance policy must have a referral from their primary care provider. Most PCPs have their own form / system, but they do need my NPI and contact details to complete the process. This example nutrition referral form outlines the details needed for a referral, my contact details, and some sample diagnoses insurance may cover.

Terminology

In-Network vs Out-of-Network:

In-Network

Individual providers (and institutions) can choose to “contract” with insurance companies. For nutrition professionals, that means we apply to be part of an insurance company’s network of providers. By doing this, providers agree to the terms of the insurance company and are considered “in-network.”

I am in-network with Aetna, Blue Cross Blue Shield, Harvard Pilgrim, and Mass General Brigham. That means I can bill them directly. While I bill every company the same rate, I am not paid the same by each company. But by being in network, I agree to their terms / conditions / rate, which varies by company.

Out-of-Network

If a provider is not contracted with a company, they are considered “out of network.” That means there is no agreement in place or terms that limit the provider. So providers bill clients at whatever rate they set, and clients are responsible for payment.

As a side note, this is often why many providers choose to not be in-network with insurance – because they cannot afford to operate on the rate that the insurance companies are setting.

If a person’s insurance policy has “out of network benefits,” clients can submit a “superbill” to the insurance company and get reimbursed by the insurance company for some or all of the cost, depending on the insurance company’s policy. Superbills are detailed receipts from providers regarding the services. They are generated after clients pay. Often insurance companies maintain internal limits around how much they will cover for different services, reimburse clients at that rate.

HMO vs PPO

Health insurance policies often come in two varieties – HMO and PPO. The type of policy someone has determines how a client can use a network of providers. There are many differences with these policies in terms of cost and access, but here are the specifics for nutrition counseling

HMOs (Health Maintenance Organizations)

HMOs put primary care providers (PCPs) at the center of care. Clients have to identify their PCP when they sign up for the policy. That often means you cannot see a specialist or other provider unless you have a referral from your PCP. The referral cannot come from another medical provider (eg, an endocrinologist can’t write the referral. It has to come from the PCP).

The referral determines the reason for the care (diagnosis) and authorizes a certain number of visits. The referral has to match how I bill for visits and that means my notes have to match the referral!

Most PCPs have their own process for writing a referral and it covers all the necessary details. This is a sample referral form for nutrition counseling that includes my NPI and contact details (which PCPs need for the referral) as well as some sample diagnostics codes insurance might consider.

It’s worth knowing that just because a PCP authorizes it, doesn’t mean insurance will cover the visits – it is still subject to insurance policies / procedures.

PPOs (Preferred Provider Organizations)

PPOs on the other hand allow clients to work with specialists and providers without prior review and/or referral from their primary care provider

Billing Rates and Balance Billing

Insurance companies set a lot of rules around services that determine how they pay providers. These include :

The rate they’re willing to pay for a given service
Location limits (telehealth vs in person)any limitations (eg, location of the visit like telehealth vs in person)
The allowed number of visits per year
The diagnoses they’ll cover
What the client responsibility is around payments (eg, co-pay, co-insurance, deductible).

If a provider is in-network with a company, they agree to these terms. They are required to accept the rate set by the insurance company and cannot balance bill.

As an example: If I set my rate as a provider at $1000 per hour, I can bill that to insurance. But if my contracted rate with insurance is $100, I cannot bill the client for the remaining $900.

What is billed to clients are things like co-pays, deductible, and co-insurance. But that is based on the rate that insurance pays.

Deductible, Co-Pay, and Co-Insurance and Out of Pocket Maximums

When insurance was developed, companies were concerned that is services were covered 100%, folks would “take advantage” of the “free care” (even though it’s not free….). So they devised things like deductibles, co-pay, and co-insurance as a way to make clients financially accountable.

Deductible: A deductible is the amount of money you, as the insured, must pay out-of-pocket for covered services before your insurance company starts paying for those services. This re-sets each year.

Co-Pay: A flat free paid for each service. Dietitians are viewed as “specialists” so often that co-pay is applied for medical services.

Co-Insurance: The amount, generally expressed as a fixed percentage, an insured must pay toward a covered claim.

Most policies that have client responsibility also have “out of pocket maximums” for individual and family policies. That means that once you’ve paid a certain total every year, some aspects go away depending on the policy (eg, you may no longer have to pay co-insurance).

Medical vs Preventative Care

Whether a diagnosis is considered “medical” or “preventative” can impact not only the rate that the provider is paid but also whether or not the client’s financial responsibility is applied.

For example, some policies will waive the co-pay, deductible, or co-insurance if nutrition is billed as “preventative” instead of “medical.” It is worth clarifying this with insurance up front. While preventative visits might reduce client responsibility, it can sometimes reduce the rate that the provider is paid or how many visits are allowed.

Which diagnoses are defined as preventative vary by insurance carrier. Some insurance companies consider preventative visits as those with diagnoses around BMI (“overweight” or “obesity”), cholesterol management, glucose management . But that is not 100% consistent and can vary by carrier.

There’s also a code called “z71.3 dietary counseling and prevention” that some carriers will cover, but not always. This is one option that can be used if there is no other diagnosis that applies to the case.

Generally, care around eating disorders is considered “medical” and so patient responsibility is applied.

It’s worth knowing that providers can only bill for a diagnosis that they providing care for. The clinical note has to have evidence that the care is inline with that diagnosis.

How dietitians document and bill

When dietitians bill insurance, we have to include the following information :

CPT code: These are “procedure” codes that every medical provider uses that communicates the type of procedure or service provided. Commonly, dietitian bill visits as 97802 or 97803 – these are the CPT codes that communication “medical nutrition therapy”

ICD 10 code: These are “diagnosis codes” that tell the insurance what the services are meant to treat. Not all medical conditions can be “treated” by a dietitian. For example, I cannot bill insurance for a concussion. But I can bill in regards to the nausea stemming from the concussion. If you contact your insurance, it is helpful to have a diagnosis code from a medical provider to verify coverage. Or you can ask the representative if there are any diagnoses they will not cover.

As part of care through insurance, providers have to keep medical records that are subject to insurance audits. What we have in our note has to match the bills we are billing to insurance. We need to provide ‘evidence’ that we’re providing care in line with our billing.

This means the diagnosis, date of service, duration, and interventions all have to make sense. We can’t bill for diabetes but not have any evidence that is what we’re helping treat.

If notes don’t align, insurance can take back the money they have previously paid and/or providers can be removed from the insurance panel.

Summary

Insurance coverage for nutrition counseling can be a blessing that allows some folks to have more access to care. But it’s not a perfect system. The best way to avoid surprises is to contact your insurance company to understand your benefits and limitations in advance. But please know that insurance representatives don’t always understand what nutrition counseling is. That’s why

Reach out if you have any questions!

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Insurance Coverage and Nutrition Counseling