BOX 19.2


Estimated Revenues for Intensive Behavioral Therapy for Obesity Services for Medicare Beneficiaries24


Individual sessions


Current Procedural Terminology code G0447 $25.75 per unit (15 min) × 22 sessions $566.50 per patient per year Note: Medicare may pay up to 2 units per date of service. Group sessions


Current Procedural Terminology code G0473 $12.54 per unit (30 min) per patient × 22 sessions $275.88 per patient per year


Additional tips for practices with fee-for-service payment arrangements with payers include the following:


ƒ If obesity or overweight is an excluded diagnosis under an individual plan or if coverage is limited, consider submitting a “medical necessity” request.25


ƒ Do not let denied claims stop the pursuit of payment. Both providers and payers make mistakes submitting and processing claims. These mistakes are often easy to fix and can lead to payment success.


ƒ Manage the practice’s payer mix (the percentage of revenue coming from private insurance companies vs government insurance programs vs patients that pay out-of-pocket) to ensure a healthy bottom line. For example, you can do so by negotiating fees when possible with payers who pay less and targeting a higher number or percentage of patients for your practice from higher-paying payers.


Value-Based Payments


Health care payments are shifting from volume-based (ie, fee-for-service) to value-based payments, in which provider payments are tied to cost and quality tar- gets. There are four main types of value-based payment models, all of which share the same four goals: better outcomes, lower costs, improved patient experiences, and better clinical experiences. This shift away from fee-for-service offers oppor- tunities to structure new, financially viable models for MNT services for obesity and overweight. For example, “per member, per month” payments can be used to fund RDN positions on the weight management team.26


Bundled payments, shared


savings, and quality incentive programs offer other mechanisms for covering nutrition services, as MNT provided by RDNs has been shown to improve clinical outcomes (eg, weight, BMI, waist circumference, hemoglobin A1c, blood glucose, lipids) and lower costs of care.27,28


Practices and institutions participating in


alternative payment models, such as episode or bundled payments for orthopedic procedures,29


can consider building the cost of presurgical and postsurgical weight


loss interventions provided by the RDN into the total cost of care. Pilot programs conducted by the Centers for Medicare and Medicaid Services Innovation Center, such as the Comprehensive Primary Care Initiative Plus (CPC+)30


and Primary 354 SECTION 4: Models and Insurance Coverage for the Treatment of Obesity


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