Like most everything in the world of insurance, there's no one-size-fits-all way insurance companies categorize services. But there's one category that spans all Nutritional Therapy: preventive vs. medical.
Preventive care services include visits for symptom-free or disease-free patients, where the purpose of the visit is to prevent a condition. Whereas medical care services are for the treatment of patients already exhibiting symptoms or diagnosed with an existing condition. For example, if your patient sees you because she has a family history of diabetes, that would be considered a preventive visit. If your patient sees you because he has high blood sugar, that would be considered a medical visit.
How claims are paid varies by insurance company and patient policy, but we’re here to help you get a better sense of those differences.
Under the Affordable Care Act, RDs are eligible to provide preventive services, including dietary counseling and obesity screening and counseling, which will be covered in full by the insurance company. However, preventive service claims are processed differently by insurance companies.
Most insurance companies define preventive nutritional counseling as the treatment of a patient that is obese or overweight with at least one additional cardiovascular risk factor (eg. hyperlipidemia, hypertension, etc.). Some insurance companies won’t pay a claim as preventive unless it includes diagnosis codes that fall under their criteria. Other insurance companies consider any form of dietary counseling and surveillance preventive and will typically pay a claim as preventive with just the Z71.3, dietary counseling and surveillance, code.
The good news is, regardless of how it's defined, if a claim is processed and approved as preventive, it'll always pay at 100% of the allowable amount! No copay, no deductible, and no coinsurance.
If the claim doesn’t qualify under the patient’s plan’s definition of preventive nutritional counseling but the plan covers nutritional counseling as a benefit, then it'll fall under medical nutritional counseling. Depending on the patient’s plan, Medical nutritional counseling claims are more likely to be processed with a patient cost-share, like a copay or coinsurance.
In some cases, patients’ plans only cover nutritional counseling if it falls under preventive.
Whether a claim is processed as Medical or Preventive Nutritional counseling, it's important to set expectations with your patients. Read our two-part series on Patient Policies on how to establish relationships with your patients and their insurance policies early on!
The Healthy Bytes way
So, where does Healthy Bytes come in? Using our billing expertise, we can generally gauge whether a claim will be processed as preventive or medical by your patient’s insurance insurance company. We file the claim accordingly, using the necessary codes and wait for you to get paid.