Part 2: Accepting Insurance

Building a Virtual, Insurance-Based Nutrition Practice

From Day 1, I knew that accepting insurance in my practice was something I wanted to do, especially given the niche that I work in.  I knew that my focus would be on men with heart disease, and I wanted to help them utilize their insurance benefits to their fullest potential. 

I had no clue where to begin other than I needed an NPI and had to sign up with CAQH so that’s where I started.

What is an NPI?

The National Provider Identifier Standard (NPI) Number is your own unique number as a Healthcare Provider. According to CMS.gov, “covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA.”

There are two types of NPIs: Type 1 and Type 2. Type 1 is for an individual.  Type 2 is for a Group or Organization.  It is important that you apply for BOTH types when planning to credential with insurance companies.  I highly recommend applying for these two types. It is free to apply by clicking here: https://nppes.cms.hhs.gov/#/  Make sure you write these numbers down, and keep them safe!

Your individual NPI can be tied to one or more tax identification numbers/employer identification number (EINs).

The Organization NPI (Type 2) is for group practices. If you are considering forming a group practice, or is incorporating, you will need to obtain an NPI for yourself (Type 1) and an NPI for your organization or group practice (Type 2).

NPIs are required for becoming credentialed with payers.

NPI Specialist Taxonomies

“Healthcare Provider Taxonomy Codes are designed to categorize the type, classification, and/or specialization of health care providers. When applying for an NPI, a health care provider must select the taxonomy code(s) or code description(s) that most closely describes the provider’s type. You can select more than one taxonomy if applicable.” First Steps to Becoming a Provider. Academy of Nutrition and Dietetics. 

Dietary and Nutritional Service Providers:

• Dietetic Technician, Registered – 136A00000X
• Dietitian, Registered – 133V00000X
  • Nutrition, Gerontological – 133VN1101X
  • Nutrition, Metabolic – 133VN1006X
  • Nutrition, Obesity and Weight Management – 133VN1201X
  • Nutrition, Oncology – 133VN1301X
  • Nutrition, Pediatric – 133VN1004X
  • Nutrition, Pediatric, Critical Care – 133VN1401X
  • Nutrition, Renal – 133VN1005X
  • Nutrition, Sports Dietetics – 133VN1501X

What is an EIN/Tax ID?

An employer identification number (EIN) or Federal Employer Identification Number (FEIN), also known as a business tax ID, is a unique nine-digit number. The EIN is the corporate equivalent to a Social Security number and is used when filing taxes for your business to protect your Social Security number from being disclosed on W-2s and in transactions, such as claims sent to health plans.

Apply for an EIN

In order to understand these next few steps, there are two terms that I’d like to highlight: Provider and Payer.  YOU are considered the Provider. You are providing medical nutrition therapy as a Registered Dietitian Nutritionist. Health Insurance is either funded by the Government such as Medicare and Medicaid or Privately such as Aetna, Blue Cross Blue Shield, etc.  Regardless as to how the health insurance is funded, these insurance companies/organizations are collectively referred to as Payers.  

Determining which insurance companies to credential with

1. Speak to local doctors, healthcare providers, and other dietitians in your state to see what insurance they accept
2. Join the Insurance Credentialling and Business Facebook Group
3. Reach out the Academy of Nutrition and Dietetics Reimbursement Representation to assist you 

What is Credentialing?

Credentialing is the process used to assess and verify the qualifications of a healthcare provider. Many insurance companies require RDNs to become credentialed in order to provide services for their members and in order to pay claims.  In order to start the credentialing process, you need to determine which insurance networks you would like to become a part of. Then, you must complete and submit an application for enrollment.  The application may be a uniform application such as CAQH (see below) or an application specific to the commercial/private payer. Be sure to make sure all the application(s) forms are complete and then submitted.  The credentialing process varies by payer. Sometimes, it may take as quickly as a few weeks. Other times, upwards of 6 months.  

Be Patient! Unfortunately, this is the longest part of the entire process.  Make sure you complete all application forms and provide all necessary documentation to help the review go as quickly as possible. Also, insurance and state policies vary. Some insurance networks may even be closed to new providers. There are many nuances that can delay the credentialing process but be patient and persistent! You can always follow up with a call to find out where they are in reviewing your application as well.

What is CAQH?

The Council for Affordable Quality Healthcare (CAQH) is the healthcare industry’s premier resource for self-reporting professional and practice information to health plans and other healthcare organizations. In a nutshell, it allows you to keep your practice information up-to-date, credential with insurance payers, and assist with claim administration.  Most insurance companies will pull the information from your CAQH to credential you with their insurance company. However, always check with individual commercial/private payers to ensure you provide all the information they are looking for.

Register by clicking here: Proview Registration

Professional Liability Insurance (A MUST!)

One of the documents need to complete your CAQH application is a copy of your Professional Liability Insurance Policy. A Professional Liability Insurance Policy will cover you incase of malpractice as well as other areas of nutrition practice. I utilize Proliability by Mercer. If you are a member of the Academy of Nutrition and Dietetics, you can also receive a discount.  Learn more about Proliability by Mercer

What is Contracting?

Once the payer reviews your application, determines all of your information matches who you are and what you do, and are accepting new providers, you will now be sent a contract, usually via email. MAKE SURE YOU READ THE CONTRACT IN ITS ENTIRETY! If you have any questions, make sure you address them prior to signing.  Also, MAKE SURE THAT THERE IS A FEE SCHEDULE IN YOUR CONTRACT. Unfortunately, most insurance companies omit this very important detail for us dietitians which is essential to our reimbursement.  Ask for the fee schedule if it is not already in your contract. Once you review the contract, you will sign it, usually via an electronic signature.

CONGRATULATIONS! You’re now officially accepting insurance!

You’re now contracted with a few insurance companies. But how do you go about submitting claims? What the heck is a claim and how do you get paid? All great questions! I’m going to very briefly explain the basics below.

What is a Health Insurance Claim?

It is a document that is submitted to a patient’s insurance company specifying the medical services rendered. It is what allows you to be paid for your nutrition services.

A CMS-1500 Form is a standard paper or electronic form that contains all the information most insurance companies will need in order to appropriately file the claim.  It includes the patient’s address, insurance information, procedure codes (CPT), Place of Service Code, Diagnosis(es) codes, and provider information.  

What is a Clearinghouse?

In order to file the claim electronically to submit to the insurance company, a clearinghouse is needed. A clearinghouse is “an intermediator between the provider/practice and the insurer where the provider can electronically submit claims. The clearinghouse checks for errors and then sends the claims to the appropriate insurer for review.” Examples of clearinghouses include Office Ally, Availity, and LightningMD. Some Electronic Medical Records automatically have a Clearinghouse as part of the EMR. An example is Simple Practice. It allows you to electronically submit the claim without you having to leave the platform or utilize additional software.

Personally, I started out with Office Ally and then switched to LightningMD to utilize with my EMR which is Practice Better. So far, it’s been working out pretty well for me, along with a lot of trial and error. If you want a more streamlined approach, Simple Practice may be better for you.

If you want to make your life a bit easier, find a mentor!

I did all of these first beginning steps on my own as well as purchasing courses along with the way from some other great dietitians.  However, I still felt like I wasn’t fully understanding insurance to the best of my abilities and how to optimize my client’s insurance benefits. Enter the one and only: Amy Plano, the Reimbursement Dietitian. I joined her group Reimbursement program about 3 years ago now, and I’ve never looked back! She has been instrumental in my growth and development as an insurance-based dietitian. She’s been where you’ve been: in the trenches learning and growing from mistakes. 

Save yourself some time and energy. Invest in yourself and your practice by investing in her programs.  She provides so much value and can save you a lot of time and energy trying to navigate this by yourself. PLUS, her program is now approved for 40+ CEUs! Level 1 of her group coaching program is for dietitians like you just getting started with their insurance-based practices. If you’re interested in her group program AND want to save 10%, use coupon code “HEATHER” and click here.