How to Use Insurance for Nutrition Services
Well, your doctor recommended you see a dietitian or nutritionist and now you are stuck navigating if your insurance will cover these services. You think there could be some benefit from working with a dietitian but the idea of financing services without insurance is daunting and incredibly confusing. Hopefully this blog post will help alleviate some of the confusion and help you understand how it all works. Or at least how some of it works because most of us providers are a bit in the dark as well!
When working with any medical provider there are two routes one can take. One being the insurance route. Meaning your provider accepts your insurance and bills them instead of you. The second being out of network providers who will bill you as the client at the time of service. We will explore both of these situations.
Situation 1: A dietitian is out of network – meaning they do not accept your insurance plan.
Why doesn’t a provider take insurance?
There are many reasons why a provider may not take any insurance. Insurance reimbursement rates vary by state which is why in some states you may see many dietitians taking insurance, while in others you may not. I can only speak to the work and school required to become a dietitian – a master’s level degree, 1200 internship (unpaid) hours, and then money spent on the exam itself to become credentialed. And 75 continuing education credits every 5 years (not including those required by individual states for licensing). We put a lot of time and money into not just getting, but also maintaining, our credentials and licenses to provide the most up to date care to our clients. Our field is one that is evidence based. And that evidence base is constantly being updated and growing. As many medical providers will say, insurance reimbursement rates are not as high as they should be in many parts of the country. This is why you may see providers who are entirely out of network, or some like myself currently who only take a few insurances.
What are some of the issues with taking insurance?
Insurance can seem like it’s all rainbows and unicorns until you actually start billing and notice your client’s plan covers very little. Opening up the door to billing insurance can be scary because ultimately you are transferring over care. Insurance can, and in many cases will, dictate care – length of care, length of coverage, amount of coverage, if coverage extends to higher levels of care, etc. Many providers have issue(s) with insurance companies, who are not dietitians or medical providers, making these decisions for their clients. I agree wholeheartedly with this and find it to be a big issue in the healthcare system. Those without experience, degrees, and educational background should never be dictating care or making decisions about it.
What if I can only find an out of network provider?
Individuals need to be seen and have access to care, so what happens if they have no other option than seeing an out of network provider? If you or someone you know finds themselves working with an out of network provider it does not always mean they will have to pay for all services out of pocket. Many insurance plans offer what are called out of network benefits as part of their plans. This means that there is some coverage for seeing a provider that is not in the network. The first thing you should do when thinking about receiving out of network services is to reach out to your insurance and ask about your out of network benefits. Some plans offer a certain percentage that is covered, some offer none, some have a deductible, etc. You get the idea that it varies across the board. To my understanding, the only insurance that pretty much never has out of network benefits are Kaiser plans. Many other national plans do offer out of network coverage.
How does billing work with an out of network provider?
When working with an out of network provider you will pay the private-pay rate for services at the time of services. For example, my private pay rate is $160/50 minute session. If I saw you as a client for one session, I would charge you $160. I would then provide you with a superbill. A superbill is an itemized receipt showing what you paid for services over a specific amount of time, usually a month. This superbill has all the information (diagnostic codes, procedure codes, etc.) to be provided to your insurance plan for out of network reimbursement. As stated before, out of network reimbursement is not guaranteed and must be confirmed with your individual insurance plan. Regardless of if they reimburse you, you are still required to pay the provider the full fee.
Tell me more about superbills…
Superbills will have diagnostic codes and procedural codes listed on them. A diagnostic code is a code providing your diagnosis and reason for being seen. A procedural code explains what service(s) has been provided. Usually for dietitians it will be a medical nutrition therapy based code since that is the service we are legally allowed to provide. It is pretty surprising for many people, but dietitians cannot diagnose anything. It is out of our scope of practice to do so and therefore illegal.
Diagnostic codes are called ICD-10 codes. Dietitians can only provide clients with Z-codes for billing. Some examples of Z-codes are Z71.3 Dietary Counseling & Surveillance or Z72.4 Inappropriate Diet & Eating Habits. They are very generic codes. Occasionally these codes will get reimbursement on a superbill. However, sometimes clients have diagnosed medical conditions that we are treating with nutrition counseling. Some examples may be an eating disorder, diabetes, celiac disease, etc. In order to utilize these on a superbill we need to have documentation from the diagnosing provider since we cannot diagnose. This can be a physician, therapist, or psychiatrist. It’s hard to say with insurance benefits whether a Z-code or an ICD-10 code will get more reimbursement. It varies across the board. We encourage you to ask your insurance about reimbursement rates for both of these codes. We can then utilize the code that gets you the most reimbursement.
Situation 2: A dietitian is in network – meaning they accept your insurance plan.
Yay, the provider takes my insurance! That means I do not have to pay right?
If a dietitian accepts your insurance plan it does not mean that all your nutrition counseling sessions are covered in full. Every plan is different and every insurance is different. With the implementation of Obamacare many insurances do offer preventative benefits for nutrition. This means that there are often a specified number of visits an individual can have that are fully covered with no cost or cost-share (copay) from the individual. Preventative visits are limited however; and every insurance has specific criteria you have to meet to qualify for these visits. Some insurances offer up to 26 visits of preventative care, which is equivalent to a session every other week for a year to those that meet the criteria. Some of the criteria include BMI ranges (yes this is very fatphobic and against HAES but if we can take advantage of the system to help clients financially, then we will). Other criteria include family history of sudden cardiac death or conditions related to diabetes.
What happens if I do not have preventative benefits or I have used them all and still want sessions?
If you have preventative benefits under your plan and have used all of them; or if you simply do not meet the criteria for preventative benefits, you still have options. What usually happens when preventative visits are exhausted is clients will then have a cost-share. A cost-share is another term for copay. Dietitians are considered specialists in the field so your copay will be whatever your plan allots for a specialist. This can range from $25-$200 depending on the plan and will be paid directly to the provider at the time of service. The remainder of the fee for the session will be paid by your insurance plan to the provider based on the fee scheduled agreed upon between the two. You will only be responsible for the copay.
Remember that insurance dictates care. They have access to your medical records and can decide when they want whether or not you require more sessions with your dietitian. If insurance decides that you do not need more sessions, they can deny coverage and ultimately force you to then have to pay out of pocket. We as dietitians fight for our clients and document accordingly to try and promote continued coverage. Unfortunately however, we often do not get a say in situations such as these. If coverage is denied or exhausted you can still see the provider but you will then be considered out of network and have to pay the full fee at time of service.
Even though insurance is complicated and not entirely fun to deal with as a provider, it does increase accessibility to care for many individuals. We hope that this post has cleared up some of your questions regarding insurance. You can access our financial PDF here for further details regarding ICD-10 codes and out of network reimbursement.
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Note to Self Nutrition LLC is an outpatient dietetics practice specializing in the treatment of eating disorders, women’s health and fertility including PCOS, endometriosis, and hormonal imbalances, diabetes and prediabetes, disordered eating, along with other chronic health conditions such as heart health, hypertension, and kidney disease. Owner and dietitian Lauren Hirschhorn-Tieu is passionate about empowering individuals to build trust with their relationship with food and their body. Lauren provides multiple services including nutritional counseling, recovery coaching, supervision and nutrition presentations. In person availability is offered in Denver. Virtual telehealth services are offered in Maryland, Virginia, Washington DC, Colorado, and Florida. We would be honored to join you on your journey to discovering food and body peace!
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