How to Obtain Pertinent Medical Information for Benefits Verification and Claims Submission

As a Registered Dietitian Nutritionist (RDN), obtaining the right medical information for benefits verification, treatment planning, and claims submissions is essential for ensuring financial transparency and reimbursement for services. This page will guide you through the key steps in verifying patient benefits, securing accurate referrals, and complying with regulations like the No Surprises Act to protect your practice and your patients.

1. Methods to Obtain Medical Information

RDNs can use several methods to obtain the necessary medical information to verify benefits, process claims, and ensure proper treatment. The process will vary depending on whether the patient was referred by a physician or is self-referring.

• Self-Referral: If a client does not need a physician referral, they can facilitate the release of medical information directly with their consent.

• Physician Referral: When referred by a physician, the office may share pertinent information as per HIPAA policy, allowing the RDN to verify diagnosis and treatment details.

• HIPAA Agreement/Release: To ensure compliance, an RDN can request a specific release of information authorization or have the patient sign a notice of privacy practices. This helps coordinate care, verify diagnoses, and manage billing.

2. Key Information for Verifying Patient Benefits

When verifying a patient's insurance benefits for MNT services, there are several key pieces of information you will need. A standard intake form or referral page is helpful for collecting all necessary details.

Required Information:

• Patient Demographic Information: Full name, date of birth, address, and contact details.

• Insurance Information: Primary, secondary, and tertiary insurance details.

• Medical History and Active Health Concerns: Some policies may not cover a particular diagnosis but might cover MNT for other conditions. Clarifying this with the patient’s healthcare provider can prevent delays in processing claims.

Example:

A patient may be referred for obesity treatment (ICD-10 Code E66.9), but their insurance policy may only cover MNT for diabetes. The referring physician’s office might need to update the diagnosis to include diabetes (ICD-10 Code E11) to ensure the insurance will cover the claim.

3. Verifying Coverage and Benefits

Benefits verification is a critical step in the claims process to avoid complications. By confirming benefits ahead of the appointment, you can provide cost transparency and avoid the burden of chasing unpaid claims after services are rendered.

• Online Portals: Many insurance providers offer portals for easy verification of benefits.

• Direct Contact: If the online portal is unavailable, contacting the insurer directly can also provide clarity on coverage details.

Why Verify Benefits?

• Improved Financial Health: Verifying benefits before an appointment helps prevent unexpected patient charges.

• Cash Flow Optimization: Ensuring coverage in advance means less time spent resolving denied claims or chasing payments.

4. Referral Requirements

Accurate referrals are essential to ensuring that your services are covered. Some managed care organizations require electronic referrals for specialist services like MNT. Keep in mind that while some insurers may accept referrals from nurse practitioners or physician assistants, Medicare requires referrals from MDs or DOs.

• Best Practice: Always obtain referrals with the appropriate diagnoses to ensure reimbursement. RDNs cannot diagnose conditions, but accurate diagnosis details are crucial for claims.

5. In-Network vs. Out-of-Network Benefits

• In-Network Providers: These are dietitians who are credentialed with specific health plans. Patients often incur lower out-of-pocket costs when seeing in-network providers.

• Out-of-Network Providers: Providers who are not credentialed with a health plan. Patients may face higher out-of-pocket costs or no coverage for services.

It's essential to confirm whether your practice is in-network with a patient's insurer to avoid billing surprises.

6. The No Surprises Act (NSA)

Effective January 1, 2022, the No Surprises Act aims to protect consumers from surprise medical bills when receiving services from out-of-network providers in in-network facilities. RDNs should ensure the following practices to remain compliant:

• Verify Insurance Coverage: Always confirm the patient’s insurance status before services are provided.

• Provide Good Faith Estimates: For uninsured or self-pay patients, provide a clear, accessible good faith estimate of costs before services are scheduled.

• Clear Billing Policies: Ensure your practice has a written financial policy that explains fees, patient financial responsibility, and any potential billing issues.

• Notification and Consent: Provide clear notices regarding balance billing restrictions and ensure patients sign a financial policy acknowledging their understanding.

7. Best Practices for Billing and Compliance

• Sign Financial Policies: All patients should sign a financial policy, acknowledging their understanding of billing procedures.

• Itemized Estimates: Provide an itemized good faith estimate for patients who are uninsured or out-of-network.

• Use the NSA Template: Provide a one-page notice that includes required information about balance billing restrictions, applicable state law protections, and contact information for dispute resolution.

Protect Your Practice with Proper Benefits Verification

Ensure your dietetic practice runs smoothly by implementing proper benefits verification, referral management, and insurance compliance practices. At Dietitian Practice Pro, we help RDNs navigate insurance systems, manage referrals, and ensure compliance with regulations like the No Surprises Act.

Take the next step in securing your practice’s financial health. Contact us today to learn how we can assist with benefits verification, streamline your billing process, and ensure your practice thrives!

Contact Dietitian Practice Pro Now