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Opportunity Description Issues Care manager evaluation and management as an independent provider “Incident to” care of a provider. Allows certain care manager types to bill evaluation and management codes for care manager work in conjunction with the care of a primary care physician Only certain professional types are allowed to use this option, for example, RD and Master of Social Work since they are considered independent providers
Nurse or other provider visit (99211) Office visit for the evaluation and management of an established patient that may not require the presence of a physician Does not pay that well for a visit that often lasts a long time
T-codes Encounter-based billing that allows specified allied health professionals phone or in person visits for disease management for patients with specified chronic conditions Only some insurers have and pay on t-codes
Often involves patient copay
Allows phone or in-person visit
Medical nutrition therapy (MNT) provided by a registered dietitian (RD) Nutrition counseling provided by an RD Only used by an RD
Limited number of visits (3 hours total first year)
Must have specific diagnosis (diabetes or chronic kidney disease)
Per member per month fee payment Usually paid for an entire population, set amount paid to the practice whether care management is given or not May be difficult to correctly attribute the amount needed for the practice population; some arrangements are based on performance metrics achieved
Medicare wellness Completion of wellness visit as specified by Medicare Must be enrolled in Medicare anytime in first year
Visit requirements for assessment and prevention plan
RD, registered dietician.
Opportunity Code and Per-Unit Revenue Billed Collected Care manager evaluation and management billing variable $66,393 $38,276.01 (58%) Allied professional visit 99211, $35 $25,168 $15,186.15 (60%) T-codes 1015, $70
1019, $35 per 15 minutes with a maximum of 2$37,158 $34,413.60 (93%) Registered dietitian medical nutrition therapy 97802, $35
97803, $32$3,420 $2,287.15 (67%) Per member per month fee payment Not applicable $0 $0 Medicare wellness visit G0402, $191; G0438, $208; G0439, $137 $0 $0 Total $132,139 $90,162.91 (68%) Care Manager Type Nurse (LPN and RN) 2.45 Full-Time Equivalent (FTE) Social Work 0.6 FTE Registered Dietitian 0.9 FTE Care manager evaluation and management 0 $5,870.16 $32,405.85 Allied professional visit $12,662.26 $1,790.28 $733.61 T-codes $16,420.06 $2,268.39 $15,725.15 Medical nutrition therapy 0 0 $2,287.15 Total revenue collected $29,082.32 $9,928.83 $51,151.76 Per FTE $11,870.33 $16,549.72 $56,835.29 Per patient enrolled $69.24 $84.86 $302.67 LPN, licensed practical nurse; RN, registered nurse; FTE, full-time equivalent.
Issue Illustrations Patients not willing to pay for care manager services Care manager: “Well, all of a sudden she got a bill for like a $120 … and that was the end of that. She told me that she would come back and see me when she got that bill paid off, but I don't look for her to call me up. … so that was one of my success stories you know that I was really kind of clicking along with her, and I was seeing regularly.” Care manager: “And frankly I don't think that patients yet get that a nurse visit is worth any money. Now you and I know that a nurse visit can be packed with a lot more information, support, training, motivation than a provider visit, but the patients don't get that. They're not used to thinking in terms of paying a nurse for anything, so they don't value it.” Physicians not referring to care managers due to concern about payment from the patient Interviewer: “So you were getting actual feedback from the patient saying I can't afford this?” Physician: “Or a phone call where they called the front staff and they said patient cancelled visit due to cost. Yeah so I mean even if we have like 2 or 3 insurances that are on board, and say we want to get these people all the help they need because they cost us less money when their diabetes is well-controlled. Then we'll say fine.” Receptionist: “I think [the patient] saw [care manager], and we billed for the visit. It was like $212 or $230 and [the patient] ended up getting the bill, and he was really upset about it … so I think that may have affected referrals. The [providers] are hesitant to refer because they really, our patient population down here isn't, you know we have a lot of Medicaid, a lot of indigent patients. So they're really hesitant to refer if they think the patient's going to get stuck with the bill.” Problems of uncertainty about payment and what can be billed Physician: “First thing they want to know though is how much is this going to cost?” Interviewer: “And then what do you say?” Physician: “I don't always know because I don't know what kind of copay they're going to have or what is covered. What isn't covered? And I can tell them I don't know, but my front desk will try to help find that out.” Care manager: “I think that the whole money thing needs to be a little more clearcut from the beginning. A patient needs to know up front whether there's going to be a charge, how much of a charge there's going to be. When they're expected to pay it? In this state of the economy, people don't like surprises, and when the front desk staff says well we'll have to submit it and see what they pay. People don't want to know that.” Receptionist: “Who qualifies for what? What insurance pays for what? What codes get done? What does [the care manager] bill? How does she bill it? If she doesn't bill it, is the patient going to get this? Do they have to pay a copay? Can they be seen 2 visits in 1 day? That's a disaster. If they have a blood draw the same day as [the care manager], [the care manager's] the rendering, which she's not an MD, so she can't order blood. She can't order micro albumin, so then it has to have 2 encounters which link together, and then it has to be processed backwards, and it's a nightmare.” Opportunity Description Issues Per-unit quality incentives for service provision Money per person for completing testing or services recommended, eg, $10 per member for each health plan member who has diabetes and has annual eye exam Patients may not participate in services for reasons unrelated to the primary care physician or the care management services are not effective in encouraging this participation
Requires ability to capture population-based data and report
Only some insurers do this
Per-unit quality incentives for meeting clinical benchmarks Money per person for meeting clinical benchmarks, eg, $50 per member for each health plan member who has blood pressure <140/80 at last physician visit of the year Requires patient to make health behavior changes, and they may be unable or unwilling to do so or the care management services may be ineffective in encouraging these changes
Requires ability to capture population-based data and report
Only some insurers do this
Patient-centered medical home designation 10% uplift in evaluation and management billing for all services if designated Only occurs yearly
Designation line conveys “in” or “out” of designation and difficult to attribute to care management services only to meet designation
Requires up-front investment
Only one insurer pays for this at present
