Observation Deck

Diabetes Self-Management

Revenue opportunities await HME businesses that can provide DSMT.

The Centers for Medicare and Medicaid Services is leading the way to value-based care and paying for a provider’s proof of quality of service, improved health outcomes, and lower costs. Certainly, the focus of CMS is on improving care and services to those beneficiaries that use the system the most, the chronically ill. A large group of the population affected are those with diabetes.

In 2015, 30.3 million Americans, or 9.4 percent of the population, had diabetes. 1.5 million new cases of Americans with diabetes are diagnosed every year. The percentage of Americans age 65 and older remains high; 25.2 percent or 12.0 million seniors (diagnosed and undiagnosed). Lastly, in 2015, diabetes remains the 7th leading cause of death in the United States. (For additional information, read the CDC National Diabetes Statistics Report, 2017.)

All providers today either enrolled or wishing to enroll in Medicare, have a billing opportunity that they might not have been aware of, even if they currently serve patients with diabetes.

DMEPOS and pharmacy providers alike have an opportunity in the area of diabetes management. The shift to quality payment makes it imperative for providers to increase their offerings to their patients and offer services to differentiate themselves or be left behind.

One of the additional services a provider can provide is diabetes selfmanagement training (DSMT). The good news is that both DMEPOS and pharmacy providers are eligible. Also, it’s important to remember that this next round of competitive bidding removes the national mail-order restriction, so more providers can step up to the plate and specialize in diabetes.

Established criteria need to be met by the Medicare beneficiaries to make them eligible for DSMT service:

  • They must be diagnosed with diabetes.
  • They have received an order for DSMT from the physician or a qualified Nurse Practitioner treating the Medicare beneficiary’s diabetes.

Background

The Balanced Budget Act of 1997 (BBA), Section 4105(a) authorizes Medicare DSMT services coverage by a “certified provider.” This section of the BBA amended Section 1861 of the Social Security Act (the Act) by adding a new section (labeled “qq”) and provides CMS statutory authority to regulate Medicare DSMT outpatient coverage services.

This section of the Act defines DSMT educational and training services as medically reasonable and necessary. A certified provider (one who meets the standards originally set by the National Diabetes Advisory Board and revised and maintained by participating organizations) must provide these services to help the beneficiary comply with therapy or develop the skills and knowledge to manage their condition. You must describe and document these services in the beneficiary’s medical record in a comprehensive plan of care.

The DSMT program can help providers serving beneficiaries already diagnosed with diabetes. This service helps beneficiaries manage their current diagnosis of diabetes to prevent additional complications. Together, MDPP suppliers and DSMT providers can cooperate to provide a full range of service options for beneficiaries with prediabetes or diabetes type 1 or 2.

In addition, the billing provider for these services must be accredited by a CMS-approved accreditation organization.

Accreditation

DSMT can be provided by providers who meet quality standards of CMS-approved national accrediting organizations such as the American Diabetes Association, American Association of Diabetes Educators. Note: CMS has declared that The Compliance Team’s AO application is complete, and formal CMS approval as a DSMT accreditor is expected in February 2020.

DSMT programs are credentialed, not individual providers. Since DSMT is not a separately recognized provider type, providers cannot enroll in Medicare for the sole purpose of providing DSMT. DMEPOS suppliers can be reimbursed for this training if they are enrolled with the A/B MAC and meet the accreditation standards.

The training frequency for classes is straightforward. In the initial year they must provide up to 10 hours of initial training within a continuous 12-month period. In subsequent years they must provide up to two hours of follow-up training each calendar year (after the initial 10 hours of training).

The coverage guidelines for the first year: A plan-of-care must be maintained in the beneficiary’s medical record, and if individual training is needed, it must include the reason for training. A physician order that includes a statement signed by a physician indicating service is needed; the number of initial or follow-up hours ordered; and topics to be covered in training. Also, a determination that beneficiary should receive individual or group training.

If individual training is needed, the following conditions must be met:

  • No group session available within two months of date training is ordered.
  • Physician documents special needs, such as vision or hearing impairment, that may hinder effective participation in group training.
  • Additional insulin training is ordered.

The coverage guidelines for subsequent years: The group training must consist of two to 20 individuals who do not need to be Medicare beneficiaries. The follow-up training must be based on a 12-month calendar year and must be furnished in increments of no less than one-half hour. Also, there must be physician or non-physician practitioner documents that show that the beneficiary is diabetic.

An integral part of providing this service for the patient with diabetes is in performing an individualized assessment. DSMT entities must collect and record the following beneficiary assessment information in an organized, systematic manner at least quarterly: diabetic condition duration; insulin or oral agents use; height and weight by date; lipid test results and date; hba1c results and date; self-monitoring frequency and results; blood pressure and corresponding dates; last eye exam date.

A DMEPOS supplier needs to look at this from a service and product integration perspective. Bundling this service with diabetic supplies, insulin pumps, meters, and diabetic shoes. Patient education and optimal experience for the patient will be key for building your referrals and payers to recognize you as a Diabetic Care Model.

Whether a DMEPOS or a pharmacy provider, there is much opportunity in this market. It truly comes down to what your goals are for your organization and how best to meet them. As a fellow business owner, I am always looking for potential revenue streams for TCT as well as our customers. I believe this something worth considering.

This article originally appeared in the October 2019 issue of HME Business.

About the Author

Sandra C. Canally is founder and CEO of The Compliance Team, Inc., which was approved by CMS in 2006 to accredit all types of DMEPOS businesses. For more information, visit www.exemplaryprovider.com or e-mail info1@tctinc.us.

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