Revenue opportunities await HME businesses that can provide DSMT.
- By Sandra C Canally
- Oct 01, 2019
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.
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.
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
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
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.
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 firstname.lastname@example.org.