Checking Benefits for Nutrition Counseling–How, Why?

Unfortunately, it isn’t obvious on many health plans that you can see a licensed dietitian, the healthcare professional trained in working with people to reverse many of the leading causes of disease and death in the US, such as cardiovascular disease and diabetes.

Many plans did not cover this service until recent years or after the Affordable Care Act’s mandates for coverage for obesity and those at risk for diet-related disease.

Now, many plans do cover, but it hasn’t made it to common knowledge or insurance benefits packets.  It isn’t in the automated phone message system either.  You have to speak to a customer service representative by calling the number on the back of your insurance ID card.

Perhaps if everyone knew about it, there would be too much business?  I’m not sure why it isn’t advertised with your insurance.  It is cheaper to see a dietitian a few times a year outside of the hospital than to have bypass surgery in a few years with associated hospital fees.

How to check nutrition counseling benefits:

1. Turn over your insurance ID card and call the number.
2. Choose Medical.  Not dental or behavioral health
3. Supply your insurance ID and date of birth.  If given these ahead of your visit, we can sometimes help verify benefits if not busy.  You should check yourself so you can hear it for yourself.
4. Eligibility and Benefits.  Sometimes you have to select “office visit” or “outpatient service” or “specialist.”
5. State “nutrition counseling” into the voice system–you probably won’t hear it in a list of automated services
6. Ask about CPT codes 97802, 97803, 97804 (individual initial, individual follow-up, group, respectively).
7. Ask if you need a referral or preauthorization for the service.  Only some plans require this.
   1. Referrals can take a few days to a week to get from your physician’s office and may or may not require you visit your Primary Care Physician (PCP) first for a visit.  If you schedule a visit and cancel in less than 24 hours because you “just find out” you need a referral, you will still be charged a missed visit fee for reserving business hours. It is the patient’s responsibility to be aware of his or her plan’s rules and only reserve professional time when ready to have the service rendered after plan requirements are met.  We accept and bill your insurance as a courtesy and are aware of many plans that require referrals from experience, but not ALL plans in existance!  Sometimes plan rules change year to year.  Remember, it is YOUR plan, so know the rules for it!
   2. Preauthorization can take a day or two.
      1. If you don’t have a referral or preauthorization prior to your visit and your plan requires it, the service will be denied, and you will be responsible for payment.  We will aid in preauthorization requests, but will only confirm referrals if notified your plan requires them.  Referrals must be on file with the insurance company if your insurance company requires a referral.  Informal physician referrals are not required to be on file with the insurance company if your insurance doesn’t require a referral for the service.
8. Ask if there are any excluded ICD-10 diagnosis codes (some plans only cover diabetes or kidney disease, others cover dietary counseling and surveillance, e.g. Z71.3 code, others cover obesity and overweight codes).
9. Get a confirmation reference number for the call and restate your understood coverage back to the representative.  If preauthorization or referral is required, get the additional preauthorization and referral number.

We do our best to check benefits for patients with plans we are not familiar with as well, but this needs to be a joint effort to limit surprise fees that we do not like issuing nor you like paying, including late cancel fees or self-pay fees for services that would be denied due to no referral or preauthorization.

Self-pay is going to be more expensive than insurance coverage, and you should always be prepared to self-pay even if 90% (yes!) of our patients receive coverage when they properly check their benefits and follow the rules on coverage.

If you cannot make your appointment, you can reschedule at no penalty if done >24 hours of your visit by emailing or calling and leaving a message.

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