Bridging the Gap: Health Coaching and Insurance Coverage, With Sonda Kunzi

On Wednesday, October 23rd, FMCA hosted a webinar to answer one of our most frequently asked questions: Is health coaching covered by insurance? As health coaching continues to transform the healthcare landscape, understanding insurance billing and reimbursement is essential for coaches looking to expand their services and reach more clients.

In this informative session, healthcare business expert Sonda Kunzi, founder of Coding Advantage LLC, joined FMCA’s founder Dr. Sandra Scheinbaum to explore the current reimbursement landscape and what health coaches need to know about the future of insurance coverage for their services. With over 30 years of experience in healthcare business management, Sonda provided valuable insights into how health coaches can successfully navigate the complex world of medical billing and insurance reimbursement.

In this webinar, Sonda and Dr. Sandi discussed:

• The current state of insurance reimbursement and its potential impact on the health coaching industry.
• Strategies for health coaches to collaborate with healthcare providers to receive compensation for their services.
• Key billing codes and the steps health coaches can take to prepare for potential reimbursement opportunities.
• Exciting trends and developments that could shape the future of insurance coverage for health coaching.

This session is an invaluable opportunity for health coaches to learn from an industry expert and stay informed on the latest trends in insurance and reimbursement.

Watch the Replay

Bridging the Gap: Health Coaching and Insurance Coverage, With Sonda Kunzi:

Transcript

Dr. Sandi: So, I want to begin by telling you how I first met Sonda. I was listening to a webinar. It was about group medical visits, and she gave such a wonderful description of how health coaches can be used as a facilitator for those who visits and how this could be reimbursable. And so we asked her to join our faculty at FMCA, and she is wonderful. She is somebody who is in the know about an area that is so, so confusing, and that is reimbursement. But she’s going to talk to you today about where we are currently and, again, this is a very confusing subject and so, as I’m sure she will point out, it is always subject to change. So, as she’s speaking, a change could be taking place or the changes are so much related to what carrier we’re talking about, what type of insurance coverage each individual has or does not have. So, let me turn it over to Sonda Kunzi. She is our billing guru, and we will get started. She has some slides to share with you.

Sonda: Okay, guys. We’ve got an hour to work together today. Hopefully, I can get through everything. If you do have a Q&A or question… But if you do have a question, feel free to put it in that Q&A or the chatbox. I’ll do my best to fit something that can be really simply answered as we’re moving along. I will try to do that. Otherwise, we’ll hold it to the end. And if for any reason we go way over time, I’m going to offer that I will answer some questions later maybe in a document or something that we include with it. So, we’ll see how that goes.

But welcome, everybody. It is definitely my privilege to come to you and just talk about functional medicine coaching, health coaching. I’m really passionate about the subject. I have basically two passions, and they somewhat intersect when you talk about them. I do a lot of work with behavioral health, and I do a lot of work with the health coaching community as well as the functional medicine community in terms of what’s billable and what’s not. And I don’t want to start this off on a [inaudible 00:02:32.010], but, guys, you got to know this is so important to be in the know so that you never are out of compliance or you’re never in a situation where you’re out of compliance because it’s just not a good thing.

And I totally agree with what Sandi said. This could change an hour after I give the session. Although it’s not expected, things happen. All of a sudden, this new version of something will come out. And indeed we have seen where a publication comes out. It looks like it’s valid, but it didn’t give the minute details of whether something was covered or not, and it’s up to us to do the investigation and make sure that when we work with primary care providers or any type of provider that is in the space of working with health coaches, that we know the most up to date stuff and that we are just in the know. So, that’s what I’m hoping to do for you today.

You will get a copy of this, and you will also hear… If you’re a registered attendee, you’ll also get, I believe, a recording. So, don’t worry about writing these codes down. This is not about writing a bunch of notes. It’s about listening, participating, asking some questions, doing the best we can with the hour that we have.

So, let’s get started. Again, what we’re covering, we’re trying to give you what the current billing environment is, right? There’s a healthcare landscape that we can’t seem to get out of. Each year, we get a little bit closer, a little bit closer, but I’d love to see it get to the point where we actually have the ability to turn those what we’ll call Category III Codes into regular codes. I’ll show you those and talk about those right now because we do have something called Category III Codes for health coaches, but right now they’re not sitting on a billable B schedule for anybody. I’ll explain that.

I want to give you some terminology used in the healthcare arena that is definitely applicable to health coaches, and then again we’ll talk about the three different major pairs. And you might already know this, but I, kind of, have to lay it out for you so that you can understand why we would say to you, “Well, it’s different for every pair.” That gets a little confusing. And then what about starting conversations with providers so that you can get that leg in to talk about how you can make it better for their patients and have this impact overall, because really what my interpretation, and please know that I am not a health coach nor do I play one on TV, but just working with them and having a feeling and understanding in working alongside them to get billable services, I definitely know that your whole thing is about having an impact on patients for better health, right? Part of that is actually their behavior, looking at that, and that’s why, again, this sort of intersects with behavioral health in a way.

All right, let’s get started. Okay, so the building landscape is this, and you’ll see my little funny stick figures. I hope they do make you laugh a little bit. That’s what they’re there for. It’s like walking on a bunch of hot coals. You’re trying to be brave and get out there, and yet everything you’re walking on is hot coals. Absolutely true. Category III Codes are still in play. What I mean by that is a few years ago, we got Category III Codes and we’re coaching health and wellness codes. We were so excited to get that, but when it’s something as Category III, it generally says to all of those in the healthcare arena that, “Here they are. We recognize that this is going to be a service, but we’re going to put it over here because it’s new. It’s new and we don’t know what to do with it yet, but we’re going to recognize it.” The recognition is the first part. It may take years in between these steps, but please know, that recognition was a big deal. Even though those are not on a, what we call, B schedule yet, they are recognized, okay?

Your qualification as an auxiliary personnel to help manage patients under the general supervision for remote patient monitoring and chronic care management is where you’re at for the billing landscape. Please know that the Category III Codes are not reimbursable directly from Medicare, Medicaid, or any of the commercial carriers. However, when I say that, I want to be clear. It is possible that you will work with a provider who has maybe a self-insured employer in their area, and they negotiate to get those Category III Codes paid. So, that’s more or less situational, and it can happen. But likely, the answer is it’s just in Category III, and it’s not reimbursable yet. It is what it is. That’s why I don’t say it’s never going to get paid because that’s not true if you happen to be in an area where somebody’s gone to an employer, proves, beyond a shadow of a doubt, hey, if you put some of your employees with our health coaches, we’re going to reduce your spend in overall prescription. And somehow that gets managed and into a contract. So, that does happen. It’s just not something that we step out with all the time because if you send a Category III Code to an insurance carrier, you’re going to get zero reimbursement for it at this time.

All right. So, telehealth, certainly that was big. It opened the door to group sessions virtually. So, I want to be clear on this. These are things you will see in a publication called shared medical appointments. So, shared medical appointments has been around for the Cleveland Clinic for many years, but this did come into play over the COVID-19. When I go over those with you, I want you to pay attention to the health coach’s role in that and what are billable because we’re not saying the health coach is billable during that time but we’ll show you how while you are doing your, what I’ll say, behavioral type of motivational and informational group session, that the physician or, by the way, qualified healthcare professional… So, when we talk about that, we’re talking about MD, DO, CNP, and PA. And if that was too much for you, it’s medical doctor, doctor of osteopathy, certified nurse practitioner and that comes in all letters, believe me, it depends on what state you’re in. And PA would be a physician’s assistant. All of those people are those that are licensed, the level of their licensure allows them to bill direct for services that you provide under their supervision. So, we’re going to look at that. And of course, let’s not forget. You could still do cash-based services. That is totally in play. And you just work that out with your provider as a value-add to their patients, right? No matter if insurance is in this or not, we don’t want to forget about the ability to do cash-based services.

But we’re talking insurance today. So, I thought you might like a little scary bat in honor of it being close to Halloween and the fact that you probably all don’t sit down and open up the CPT book. Yeah, and these days, neither do we. It’s really something that’s electronic now, but I just wanted to say we’re going to go over these CPT codes. They are in the CPT book, so they’re valid. These are other than the Category III, and these are where you can provide services to patients under the supervision of the person who can bill them. So, there’s this billing and rendering. So, let’s get you there.

All right, so here’s our Category III Codes. Not much to say about that, but when you see this table, okay, these are the three codes that are out there. And, again, I want to be clear. This is potentially something that a clinic or a provider can negotiate with a health insurer, with an employer usually, and the employer, if they’re self-insured, they can drive some of the decision-making. But we don’t see a whole lot of that. Notice, you’ll see… Now, whenever I give money amounts, please be clear that that is at a national Medicare level, and that will vary depending where you are. And I saw some really cool check-ins there as we were starting up in chat. And we are all over the place, which is fantastic. Love to talk to the masses, but that also means that that’s going to vary a little bit, depending on where you’re at in the United States. It basically depends on what does it cost to do business in that state and that’s why the geographic location will have effect on how much is actually paid out to providers. But right now, as it stands, these Category III Codes do not have a B schedule associated with them.

All right, first thing we’re going to go through is remote physiologic monitoring. So, what this is basically is, for example, I’ll actually show you a full scenario, but this is where a patient is identified as having a chronic condition, that the provider would love to evaluate and monitor in between office visits, right? The whole idea is that sometimes things happen to patients between visits because it’s tough to get in with your primary care. I don’t know about you guys. If you’ve ever tried to make an appointment with a primary care, sometimes it’s 8 weeks out. It’s tough, but they’re looking for a way to make sure that they can be monitored in between these visits. That’s, kind of, where you come in, right?

So, the provider is going to order it, and I might be getting ahead of myself in these nice little slides, but I’m just giving you a top-level view of that. Provider orders that, “I want this hypertension monitored in between these visits because it just seems to be not even making it while I’m providing medications, or the patient’s being non-compliant and we need some help in monitoring that.” So, they set that up and they identify that patient. And then the equipment has to be purchased by the practice, okay? That’s something that’s reimbursed in that second code you see there, the 99454, because that is the thing where it’s a monthly reimbursement and it goes toward that cost of not only the piece of equipment but the software.

And then you would then, under the direction of that provider, monitor that particular patient during that month in between visits or whether it’s a couple months in between visits, but it’s a monthly billing code that gets used and then you can see that first line is “billed one time,” right? That is for the initial setup and educating the patient.

One thing I want to point out so that we’re not amiss in giving direction on this is these particular codes or this code set requires Bluetooth. The whole aspect here is that the patient isn’t involved in the reporting process. It’s something that’s hooked up to them, right? Let’s say they put the cuff on, pull it, hit a button, it registers and it goes immediately into software for view by the person who’s monitoring it. And again, you might not get it automatically. It might be something you check on a daily basis for these patients, right? That’s what you would be doing. There’d be a cohort of patients. They’d maybe all be hypertensive patients. You have to do this strategically, think of it that way. And then you would be looking at that data usually from software.

And then you would be talking with the provider to say, “Hey, I saw them spike up. I reached out to them,” which would be the next line, 99457. “I reached out to them, found they had gone out for a meal, lots of salt or sugar or carbs or whatever it may have been to spike that up. And they’re going to watch this and we’re going to make sure that this or that happens or whatever the issue is.” So, for you, it’s the monitoring piece. You are like the quarterback just looking at the patient, looking at the data. And remember, the provider is going to give you the instruction on this. They write a care plan. It’s in their hands. You’re basically carrying it out on things they just can’t get to. Now, I’ll explain that in a couple of slides how that conversation should go, but I just wanted to give you this overview.

So, on a monthly basis, this is billed. Okay, the first month we get to bill the equipment setup. We also get to bill that next line, the supply, and potentially, of course you would, do the 99457 for the first 20 minutes. 99458 is a little harder to achieve. It just assumes that you’re spending more than 20 minutes per month on that particular patient, but it does allow you to do that. So, remember, there won’t be a quiz. You don’t have to remember these numbers.

So, you’re monitoring the patient for compliance, and this is the protocol that the provider sets up. So, let’s say the patient’s blood pressure goes out of control. It’s not for you to understand exactly what point that particular patient is out of control because there’s protocols set up. You’ll be able to say to the provider, “Based on your measurements as being normal for this patient, they spiked at least three times. I called them. This is what’s going on. What would you like to do? Do you want to adjust the protocols?” Again, the provider needs to stay actively involved. It’s not a handoff and goodbye and take care of them. It’s an active involvement.

And then again, interactive communication with the patient, here’s your sweet spot, right? Encouragement, giving behavioral modifications, showing them what they can do, redirecting their thought process and stuff like that. There’s your sweet spot. That 20 minutes per month is where you shine, right? You’ve got your cohort and you’re going to be talking to people during the month to see where they’re at with their remote patient monitoring and things like that. Always directing the medical piece of it back to the providers.

All right. So, here’s our little scenario. Let’s go over. And I do see a quick Q&A. I see it in there about, can I expand on the auxiliary personnel? Hang with me because there is a slide on that. Yes, we will definitely explain who that is, okay, and why we feel that health coaching applies in that.

All right, Dr. Smith assesses John’s chronic conditions and determines he would benefit from RPM to improve his lifestyle, better manage his medications, and prevent complications regarding diabetes and hypertension. And, again, not something you have to remember for trivia, but important to understand with those RPM codes, they could be on several pieces of equipment, and it’s only allowed to be billed once per month regardless. So, if they had a glucose monitor and a blood pressure, it still would only be able to be billed once per month, okay? So, it can be multiple things that you’re looking at.

So, the provider, right? This is where we talk about how can the provider get the patient engaged in how the health coach is going to take part of this. So, the provider makes the introduction to the health coach, the health coach, and you can see where I have bold points. It’s sort of like, if you don’t want to go through this whole thing, here’s your bold points. The health coach will work under general supervision and collaborate with the care team, right? Set up the RPM potentially and train patient how to use it, okay? And then the monitor, the whole process through the software, and you can see my little picture at the bottom of the screen, it’s generally what it looks like. You use software and that whole Bluetooth thing is going on and you have the patient data to look at. And then you are escalating any issues to the provider based on trends, report alerts, and whatever the care plan was. And then certainly weekly check-ins would be great. You’re reinforcing to them their lifestyle changes. This really can have impact. I think that people forget that food is medicine, movement is medicine, and reinforcing these lifestyle changes is really at the heart of the matter with the health coach. And then again, we still need to do reporting to the provider in case they want to make any treatment plan updates, right? And the fact that you’re monitoring real-time feedback, if something spikes, we can catch it. Give it to the provider, escalate it, and keep the patient out of the hospital. That may sound like dire straits, like out of hospital, but people tend to go to the emergency room quite a bit and it can be costly. So, this is what we’re trying to avoid, the high cost of the hospitalizations.

All right, so that’s a little on RPM. Remember, what we’re touching on is potential opportunities for you to work with clinics, doctors, nurse practitioners, and PAs on ways of managing their patients outside of those office visits, right? You’re not at the qualification to do office visits or for him or her… Let’s say, he or she being the provider to bill for office visits for your work, that’s not proper. But what’s proper is these particular items that we’ve identified as saying clinical staff or auxiliary personnel under the direction of a provider. So, it is completely compliant. And I will tell you some caveats and some things to look out since we’re all over the United States. I’ll give you some things to think about, some things to investigate prior to going to providers and talking to them about it.

So, this is chronic care management, okay? So, we have the first 20 minutes of clinical staff time, and then each additional 20 minutes. Unlike RPM, right, where we had a physiological monitoring based on equipment, this is simply working with the patient on lifestyle, monitoring, all the things that go on again between visits to keep them out of the hospital. So, these are, as you can see, those 20 minutes. So, they’re by minutes. So, again, it’s really important that all of this is in documentation and that has to be figured out by that particular staff.

All right, so let’s talk about the requirements because it’s not like we can just go, “Okay, well, I can do RPM and CCM.” And we haven’t given thought to what those are. Because no matter what, okay, no matter what, I want to say this out loud, no matter what, it has to be medically necessary for that patient to be receiving those services for the conditions that they have. That’s why I still go back to the don’t forget that you can be providing services under supervision for cash. Cash means their wellness. We have well people in the world that still love getting health coaches involved. We have providers that love to have health coaches as part of their whole team based on things that may not be covered by insurance. So, don’t forget about that piece. So, when we talk about insurance, we have to be uber sensitive to the words medically necessary. If you work with a good provider, they’re going to understand that, that they have to have these qualifications. Now you have these qualifications as being part of this great session and also we’ll have it afterwards.

So, the patient has to have two or more chronic conditions. So, that would be like diabetes and hypertension, which is not really hard to get there. There are conditions, but it has to be two or more chronic. Chronic is expected to last either a year or the lifetime of a patient. Unfortunately the way they put it in the CPT book is until the death of the patient. Those conditions have to put the patient at significant risk of an acute exacerbation or death or worsening or decompensation, and that is for the provider to decide. So, if this happens to be a diabetic patient who constantly is having sugar spikes or hypoglycemic attacks or things like that, that is definitely putting them in an exacerbation and a functional decline in their… And they could be winding up in the emergency room. They could have patients like that and the whole idea, remember, is keeping everybody as healthy as we can based on the presentation of the problem, and that it’s medically necessary for them to be followed for that problem. So, those are the requirements of doing that.

So, let me just pop back real quick. These were the codes and the services. These are the requirements. So, here it is again. We have the scenario for the RPM. Now we have the scenario for the CCM. Now, mind you, I use the same patient, the same doctor. But let’s say they got diabetes and hypertension. You’re going to be working under the general supervision. The provider must do a development of a care plan, right? And so you’re using that care plan to carry out times to talk with the patient. Are you doing this? Have you done that? The doctor suggested this. Have we gotten that into your changes, your modifications, to your diet, to your exercise? You are there to do the piece that keeps that patient in line with the care plan. Okay? There may be other people in that office. Sometimes if they’re a real progressive office, there’ll be a nurse piece of it, maybe an RN or an LPN that helps with the medication stuff. But generally speaking, you’re going to do there, you’ve got to help monitor their nutrition plan. You got to keep them progress going on their care plan. That’s what that’s for. And then regular check-ins, that’s the whole payment piece is those timeframes. It’s literally calling up, doing a Zoom, whatever direct contact you have with them, that would have to be documented. And at the end of the month, we add up all those minutes. And usually, like I said, you work in a cohort of patients. And we’ll talk about doing a pilot here at the end of the session. And that’s where you’re doing. It’s not like you have one patient and you’re dealing with that. You have a group. Sometimes you’ll get on group. Totally different. All right.

So, now we’ll talk about that. I want to be really aware of shared medical appointments. There was a letter that came out from CMS, Medicare, that said that there isn’t any reason that they felt that shared medical appointment wouldn’t be payable as long as the physician billed it appropriately for the time independently and in an individual with these patients. So, I think that where this goes off the deep end and where we all get confusion are sometimes the providers believe that they can have 20 people in an hour session and they’re going to get through all them in billion M’s while you talk. Well, that’s not realistic, rigsht? let’s just take an hour and a half and maybe 10 patients. That seems a little more real because the average time spent between the provider and the patient is 7 minutes, 46 seconds. You could probably Google it and find it out there. That’s sad but true. And they are only allowed, and they would be the physician or the qualified healthcare professional, is only allowed to bill for the time spent with that individual.

Now, we’ve heard of this before COVID came around. We heard of it as they were all in a room, and as long as patients signed statements saying it didn’t matter to them if someone else heard their problems, and it was sort of this whole thing, and that’s fine. Again, I’m going to stand on that the physician, the nurse practitioner, or the physician’s assistant, sorry, has to still have that individual time that they normally would to bill that evaluation and management code. That’s what we call it. That’s an office visit, basically. And what you’re doing is you’re taking the patients into the group, having a group session, talking about nutrition, and movement, and lifestyle. And the patients are together, they still have to clarify from a HIPAA standpoint that they’re okay sharing. And usually this is something they sign as a consent. And they’re all together and they have one combined mission to get better and you may be delivering education in that group at the time. And then this would be on Zoom by the way is, kind of, what we’re talking about. And then the physician or nurse practitioner takes the patients out in a breakout room, now again we’re giving scenarios and in the background, these providers must have the ability to say they’re using a HIPAA-compliant mechanism right. Sometimes a free Zoom is not HIPAA compliant. There’s something called doxy. That’s the piece that the providers need to understand and do on their part. Everything needs to be HIPAA-compliant. Everything needs to be medically necessary, and you need to be supportive to those providers and showing them that what a benefit that their patients are getting by having a group session and that they have the ability then to see them one by one as they take them out. That’s the billable piece of it.

Sonda: Okay, hard to explain these sometimes, but it’s really important. This might, might be how it works, right? They all have a chronic condition, okay? The provider is there, they’re present, they’re on with the rest of the group, and they welcome all the patients, they talk about it, explain the group education. They talk about the requirements of the breakout sessions and how he will do that. He or she, right? And then it’s led by the health coach. So, these are the things that we’re on, healthy lifestyle, what’s going on, are you adhering to your medications, are you doing stress management, Q&A. Again, it could be whatever you design that structure or that programming to look like. Then the provider, the billable piece is the provider meeting with each patient separately, or they’re going to talk directly at a medical level of what’s going on, what have you been doing, all the information they normally do during an E&M. I think that that’s so important to understand that shared medical appointments are not something that we’re not…this is not a revenue-generating service.

This is a service… We have to think about it this way. We’ve got patients, it’s medically necessary for these people to be monitored. It’s great to put them in a group where they all agree to be, and the provider just still needs to have that individual time, and they need to keep track of that with really good documentation.

So, the billable piece on the shared medical appointment isn’t necessarily what you’re doing, but the leverage you’re providing to that physician or nurse practitioner to work with these patients one-on-one. And they get the benefit of all the good things you have to tell them on how they can continue to do good things and get information with them understanding some things that they have.

All right. So, just a quick recap before we go on, trying to keep my eye on the time too so we can get through everything. Remote physiological monitoring is an opportunity. Chronic care management is an opportunity. And shared medical appointments is an opportunity. In all of those comes some really important regulations. And we can definitely maneuver through those, navigate properly, work with the provider and their billing team to make sure nothing is amiss. And so that’s basically what I’m here for, to tell you that it still needs to be taken very seriously, and we want to make sure that the terminology everybody understands, especially this should give you, you know, I think some really good information to take to providers if you’re in that opportunity mode where you’re meeting with them.

So, this is the “incident to” provision. This is something that’s super important, and something you’ll hear a lot about. And I can tell you something that is not always followed to the manner in which it’s intended. And I’ll also need to tell you that this is a Medicare provision, meaning this is CMS’ provision for “incident to”. This is how it works. And although I can say, for the most part, commercial carriers will follow suit with this, we do still need to do some investigation to make sure that they would follow the “incident to” provision.

Again, the CPT codes that we talked about are clear from American Medical Association and the code perspective that people can work under the supervision of a provider but you will always hear this terminology in the landscape when you enter into the insurance world. What is an “incident to” provision? It basically is defined—again keep in mind, Medicare started this—a service that is furnished incident to a provider, a physician, and it literally says physician, but it does dial down to qualified healthcare professional as well to their professional service when the service is furnished as an integral, although incidental part of the physician’s professional service.

So, I know when you read that, you’re like, “Okay, that really is hard to read. And what does that mean?” Here’s my layman’s term. Patient has to be seen by the provider first. Initialize the care and put the care plan there. Services are identified as needed, medically necessary, aka, ordered and documented. And ordered just means that the provider writes it in his assessment and plan…his or her assessment plan. I would like to start remote patient monitoring to monitor this. Here’s my reason. Then they potentially set it up on a nice little format. This is what’s going to be done because what happens is the protocols and that the plan has to remain in place. And the problem is, if we veer from that and try to address any other issues, we come out of the “incident to” provision, so we just need to be careful with that, and under the supervision and carried out by identified staff.

So, to the question, whoever put this in Q&A, here you go. This is the best way we can do this. Auxiliary personnel or clinical staff. So, the reason there are two names for it is that auxiliary personnel is in the federal register. It’s defined in the federal register, which means that CMS, the Center for Medicare and Medicaid Services, has identified auxiliary personnel as being able to work under the supervision. And the AMA defines clinical staff. Generally, when we look at that, we’re seeing about the same thing, although it may be a little different depending on what service we’re talking about. But in general, on the ones that I have provided in this session, this is a person who works under the supervision of a physician or other qualified healthcare professional, who is allowed by, and this is where you got to tune in, allowed by law, regulation, and any facility policy to perform or assist in the performance of a specified professional service but who does not individually report that professional service. So, that literally means a person working as… You can be an employee, you can be a 1099, but the cost has to be to the provider. So, you’re physically getting paid by them. You would be the auxiliary personnel, and we would have to check the state to make sure that there are not any very strange laws that appear. This is something you might want to write down or necessarily if you hear this again, you may want to pick up on this, is that a lot of times the state will have something called designated or delegated. I’m sorry, delegated care. There could be a specific law about a physician’s delegated care in the state, and sometimes that’ll put some guardrails.

So, it’s unfortunate that we can’t say it’s a perfect fit for every state. Generally speaking, as long as you hold a certification, you are educated in a manner in which the services that you are providing are allowed by your state, and generally speaking, it would be in these scenarios. And again, we just don’t want to cross that line of providing a service where we’re not legally allowed to in that state. So, for example, a health coach, although providers train you on lab, you are not necessarily by law allowed to interpret labs on your own, or again, allowed to bill things on your own. So, I hope that makes sense. It is about what the service… So, we, kind of, go down this way. First of all is, what is the service that’s going to be provided? And thinking about the scope of practice that’s required, is there any licensure to be carrying out a care plan of a provider? Well, that depends. Let’s go to RPM real quick. If you’re basically managing that patient by monitoring software, looking at how is their hypertension looking, how is their diabetes looking, and the protocol is built into the software generally, where a provider is going to say, if it spikes over this, I want you to let me know. If it spikes down here, I need to know. So, you’re doing that work that they don’t have time to do in monitoring and then you’re providing the support. You’re getting on with that patient using the certification that you’ve all worked so hard for and health coaching or what have you, then you’re utilizing that to do the motivational speaking to the patient in terms of getting them to follow suit in the care plan. It’s all about that patient needing the service and whatever the service is to provide.

Let’s look at chronic care management. Yes, the provider is the one doing the care plan, but he or she’s going to say in that care plan what should be happening in between services, and that may be where you need to be. And again, it’s not necessarily about understanding the medication they’re taking and all the possible side effects. But if they talk to you about it, you can go back to your provider and say, “The patient had a concern about such and such. They feel this way. Do you want them to have an appointment with you? And I can facilitate that.” So, again, you’re facilitating back to the provider each and every time. And then the shared medical appointment, remember, the billable piece of that is the provider along with that service. The support mechanism is you providing that.

All right, let’s go to types of payers as we try to get closer and closer to where we help you out in conversation. Types of payers. Medicare versus Medicaid versus commercial. So, just trying to make sure that you understand these three big payers. Medicare is the federal government. It’s the over-65 folks. Things fall under them like, I’m sure you’ve heard of Medicare Advantage plans. Those are just specific advantage plans that process claims for Medicare patients. Medicaid is for those folks that don’t make enough money to purchase their own. They fall under a federal poverty level where they get healthcare through Medicaid. We don’t see a lot of services through Medicaid. It depends on where you are and the patient base of the provider that you may work with. And then the commercial carriers is the main thing. This is the part where they can create their own rules and policies, but generally they follow CMS. Listen, it’s not just frustrating for you, but it’s super frustrating for us as well, being consultants, when we hear that, well, yes, UnitedHealthcare might pay for remote patient monitoring, but Cigna says no. So, it’s really important, and I’m going to show you a quick little thing on how to navigate that. You really want to know what your provider’s main patient base is so that you understand how to navigate those commercial payers in that area.

So, here’s an example. What you want to do is you go and you say, “Okay, I’m working in Oklahoma.” And I’m making this up totally. “And I’m working in an area where there’s a huge population of UnitedHealthcare, and this provider says about 60% of his practice is they’re commercial, they’re not Medicare patients. So, we might want to go look for their policy on remote physiological monitoring.” And so that is what you do. You research it. Make sure you’re actually getting a policy. Look, Google’s great and so is ChatGPT, but you need reality. But you can get this publicly, right? This isn’t through any special portal that was signed in or anything like that. You can look for remote physiological monitoring, UnitedHealthcare, and then here is the way to get that. It might be Anthem, it might be Aetna. It could be a Blues that isn’t an Anthem policy. You just need to know where to go and that’s working with that provider and say, “What’s your patient base, okay? And then also what kind of chronic conditions do they have? Things like that.

All right. Provider conversations. So, again, I try to be jovial in this. I hope that you follow me on these next two slides. I am joking. So, basically what you have are the providers going, “I’m not sure. This is great. I’d love for my patients to have a health coach, but how do I do that?” And then we have our health coach in the middle going, “I have ideas. We need to talk about it.” And then eventually that leads to a successful relationship where you’re having impact on those patients and can show the work that you’re doing is actually making them better.

But we know that it actually looks more like this. You have a conversation with the provider. They say, “Oh, I think this is a great idea, but you got to speak to my biller or my manager.” And then in the middle, the biller yells, “It’s not compliant. I’ve never done this before. I’m not going to do this billing.” Now that is making fun. Just so you know, I have a billing company too and I’ve probably had this conversation with providers. So, it’s not making fun of anybody but myself. When you’ve got to know, you’ve got to be armed with not just the flowers there, but the information for that person and talk it through and make sure you get them to understand what it is. But you also have to hear them out. I mean, there are people who have been doing billing for a really long time and can tell you what potentially could be a risk factor or something they’ve seen in the… And you can address it through that. And then again, on the right-hand side, we said, “Then you feel like you’ve got to write a thesis about what your value is.” And that’s always rough. So, again, these were just, kind of, for the comic relief of all the things I had to tell you.

But let’s talk about what those conversations can really be. You could be saying things to the burnout doc. Remember, there’s a lot of provider burnout. Listen, if you even Google provider burnout or actually even do a search for provider burnout on LinkedIn or Instagram, oh, my goodness, it’s just at every headline right now. I can take on the time-consuming tasks for you, freeing up your time to work with these complex, high-risk patients. And I will monitor the ones that you put in this group, this plan, and I’ll make sure I talk with you. And then you’re literally saying, through regular communication with your patients, I reduce the number of nonurgent questions, the concerns that come in. The amount that you will free up, I’m serious, on the front desk task of answering calls in terms of what if this, what if that is incredible, and you can’t let that pass by is that you’re going to lessen the amount of phone calls that come into the office, nonurgent, right?

And then what about the patient engagement? Again, sweet spot, let’s talk about this. Your ongoing contact with these patients helps support them, feeling they’re supported between there and that improves their whole engagement. And then it’s all also about patient satisfaction. I think I may even have that on another slide, but these… Hey, imagine being a patient for a provider that it’s hard to get a hold of them. Now you’ve got diabetes and hypertension, you don’t like the fact that you’re out of control. You slip up and all of a sudden, now you have a health coach as part of the team of the office that’s going to monitor them based on what the provider, so they still feel comfortable, right? They still need that relationship with their provider. It said, “My provider put this plan in place and the health coach is there,” and they’re like, “This is really cool. I can just call them up and say, oh, I had this problem and I went out and ate a bunch of pasta and this is what happened.” And they talk through there. And I’m really probably making light of what the conversation could be, but you understand is they have the relationship that stays intact but then they also have this in-between great person. And how wonderful would it feel to have someone as part of your provider’s office that is constantly engaging you in between the office visits? Fantastic.

Collaboration. Remember, you’re going to be working closely with them. You’re not taking over any patient care. You are just mainly monitoring it through these things and giving feedback. You should be meeting with the providers. You may have things that you have to escalate to their attention quickly. You need to get the provider to understand, “I’m not here to take these patients away to bring money down. I am here to actively help you manage these patients in between your visits so that you can concentrate when you have the patient in your office and you already know what’s been happening to them for the last month.”

So, talking about empowering patients, I can’t say enough right now. In the insurance landscape, you’re going to hear this terminology quite a bit. They want the patient to be part of their treatment plan. Patient participation in that treatment plan is big with the health insurers. Did your provider go over his plan? I get surveys all the time. Are you comfortable with what your provider said? Did they address this problem? It’s all the time now, especially when those are part of bigger organizations. Like I said, the survey goes out right after. So, having that whole patient participate in the treatment plan is going to increase those survey scores.

And then the shared appointments. Again, the shared medical appointments I go into very conservatively. Again, I want to make sure that everybody does that. And that is that you could be leading the education sessions again while they give individual attention, and you’re building a community. That word, building…all those words, “building a community,” huge. Huge, right? Patients want to know there’s other people out there that are going through the same struggles that they are. And when you build that community, you’re going to get a lot healthier patients. This has been proven by people I’ve worked with before that they were able to build a community and get people better based on that whole community interaction.

All right. And then the billing and reimbursement that you’re talking to them. You can say the comment, “By utilizing service like chronic care management or remote patient monitoring, you can still provide high-quality individualized care and increase the revenue through proper use of CPT codes, right? So, you’re saying, “I am aware of these codes. We know what the codes are out there. We know that they can be different insurance carriers. What are your top three payers? I can go research that for you.” Something like that. And then knowing that your documentation is key, key, key, key. Documentation is super important and hopefully that, if anyone’s talked to you about that, documenting things that the patient says, things that you go over with the patient or the client, and everything like that, and in support of carrying out the care plan is always going to be important.

All right, so we are really close to getting through all of our slides so that we can take questions. So, hang in there, maybe one or two left. Maybe there’s a couple questions you can ask them. So, I gave us a little thought. Maybe you ask them, how are you currently managing chronic conditions in between visits? It helps that provider identify their pain points. Well, I don’t do anything. I hope the patient’s going to do what I tell them to do. You’re trying to show them, okay, you’ve got non-compliant patients. Here’s where I can really come in and bridge that gap in between visits using these types of services, right? That’s the value-add that you want to come back with or, hey, if we were able to get a software in here with real-time health data with a glucose monitor or a blood pressure, would that help? Would we be able to keep your patients out of the ER because I’ll discuss that. The way it’s supposed to happen, we purchase the service, I train them on using it. You write the care plan, I’ll monitor it. And you see the patient on your regular scheduled office, and meanwhile, yes, these are payable.

So, all right, and then do you have patients who struggle with compliance? Yes, yes, and yes, right? And then telling them by focusing on this patient engagement as a way to meeting that compliance problem for his treatment really shows how the health coach can help that adherence to the care plan.

All right. This is our last official slide. All that I’ve been providing during this small session is trying to equip you with some of the knowledge that you need to understand the insurance landscape and how that can be leveraged for you to be getting with your patients and providing these services under the supervision of a physician or nurse practitioner while we wait as the insurance start to accept and get our Category III Codes to Category I and get us on the eligible credentialing list. It’s not there yet, hopefully it does, but what you’re doing is you’re presenting that value proposition to the provider. You’re reaching out to them, you’re explaining your role, how you can potentially increase patient outcomes and improve them and things like that, and also where the workflow comes in. A lot of people… That’s the big problem, workflow. How do we make this work? And you’ll need to have an answer to that hopefully with some of the things we’ve armed you with.

Demonstrate the financial feasibility. Again, realistically, that is through the codes we gave. Now, understanding their correlation to what has to happen and where things are important to look at from a state level, from an insurance carrier. There’s still a lot there but don’t be discouraged. Let’s see if we can get those codes out there with the amounts. If you look at Physician Fee Schedule Look-up in Google, you can actually get to your state and get those actual geographic area Medicare amounts, which is where people start on what it does reimburse for your area.

And then offer a pilot program. You need to demonstrate it. So, you have a lot of hypertensive people. Why don’t we just start slow? Why don’t I come aboard and we’ll get 10 of those together. And here’s what we’ll do with CCM and RPM. And based on this model, this is what it would pay. And here’s what we’ll want. Our treatments and outcomes, this is what we’ll measure as part of this little pilot. And then you kind of go from there. So, that would be my advice. And I’m ready for questions. I left five minutes. That might not be enough time, but Sandi, how can we do…?

Dr. Sandi: Wow, thank you. This has been so helpful. And I know that people in our audience got a lot out of it. So much information here. So, those of you who would like to ask a question, you can use that Q&A, so feel free on the few minutes that we have remaining. And I’m going to start off by asking you something that you said regarding qualification as an auxiliary personnel. So, with that individual, the question is, do they need to be salaried? Because you had alluded to a 1099. So, is that going to vary by state, for example, or…?

Sonda: Great question. So, I can answer that very easily. I alluded to 1099 as a contractor, or you may be employed. It wouldn’t matter whether you were paid hourly or a salary. The only requirement is that you are a cost to the provider. So, you can’t say, “For free I’ll do this work and we’ll see how it works.” And not that you would, but that was what an auxiliary personnel is. So, the only way I could correlate this to you maybe that makes sense is when physicians see patients in the hospital, and this is a little outside of health coaching but try to follow me here for one second. When a physician would go into a hospital and see patients and let’s say the hospital themselves, the hospital employs a nurse practitioner and this physician says, “I want the nurse practitioner see my patients first and then I’ll confer with her and see my patient and etc.,” the work that’s done by that particular nurse practitioner cannot be part of the physician’s bill at all because he doesn’t have the expense. That person works for the hospital. So, the auxiliary personnel from the office perspective is he just has to pay you some way. And we want to clarify, it didn’t necessarily need to be through employment. It could be through a 1099 contract, because remember, they can also contract with outside vendor groups that actually do RPM for them. So, it can be contractual or employment.

Dr. Sandi: Okay, so this is something that, as a health coach, you can go in and really educate the practice about the ways that you can be paid as a health coach. And as you said, many ways that your patients will benefit from these services. A question sometimes comes up regarding health savings accounts, HSAs, FSAs. And so I want to be clear, if you could explain, because I had a question come up a few days ago regarding whether the coach would need a super bill for that, that they would give to a client who is then going to submit for their health savings account.

Sonda: Yeah, and basically the best thing I could say on this is I want to be careful with that, because the HSAs have special IRS requirements on what’s a reimbursable service. And I really cannot get that deep because I’m not an expert on that. But, yeah, so basically you would do a super bill, a claim form, something to the effect of that, the date of the service, the service itself was written out, and the cost of it and give that to the patient who reimbursed…the patient who paid for the service. So, it just has to be clear when the service has occurred, what the services were, and the cost of the services. And usually, that’s easily done. We could say it’s easily done through a super bill or a printed claim form from a system or an invoice, as long as it has all those elements that the HSA can make the decision on the reimbursement piece.

Dr. Sandi: Sounds good. Right, well, I’m just looking to see if any questions have come in.

Sonda: Yeah. I could see a couple that I can do quickly.

Dr. Sandi: Okay, great.

Sonda: How does it work for a Canadian health coach working? Unfortunately, I do not know. I apologize. The Canadian healthcare is so different than the United States, so unfortunately I’m no expert on that. Does this apply to CNSs that want to work under a primary medical provider? So, I’m not sure what CNS is in terms of… It could be different in every state.

Dr. Sandi: A certified nutrition specialist.

Sonda: Yeah, so a certified nutrition specialist, they actually do have the ability to be eligible as to be rendering a provider typically for what we see for diabetic codes, the 97801, -02, -03, but those are the medical nutrition therapy. So, the question mark there is the scope of practice of a nutritionist in that state. But some states, again not all, allow certified nutrition specialists to actually be eligible to be a provider. It depends on where the certification comes from, the education level. There’s so many things that we definitely don’t have enough time to talk about, and it’s really hard, but you got to, from a state level, take a look at that.

Dr. Sandi: Great. And the question about if the referring doctor or supervising is a mental health provider. I don’t think that should make a difference as long as they are properly licensed.

Sonda: Correct. So, the thing about this is, and what we want to be careful in talking about, is the psychiatrist themselves is likely not to have an RPM patient because there’s nothing from an RPM perspective that measures mental health. Now we do see something coming out on our TM that I did not go over. This is so new. I don’t want to go through anything about that yet, but a psychiatrist may in fact have two or more chronic mental health conditions in which they could utilize. And that scope would have to be discussed through the CCM services that were going to take place. What would the care plan look like? And then would that be in the scope of the person who’s doing that under general supervision?

Dr. Sandi: So, one more question, but I want you all to rest assured that we will look at all of these questions and make sure that you’re getting answers to them. But Ronda writes, “Is there anything that says reimbursement is for only certified health coaches by the National Board for health and wellness coaching?”

Sonda: So, I can tell you this. When the Category III Codes came out, there was some indication. I do believe they lessened or loosened up that particular regulation. Again, that was just talking about the Category III. From an auxiliary personnel perspective, no, it’s not necessarily that certification.

Dr. Sandi: All right. Well, we are out of time. This has been absolutely jam-packed with information. I want to thank you, Sonda. I want to thank everybody who participated. Again, you will get the recording, and we will do our best to answer those questions that we didn’t have enough time for live on the call. So, thank you all, and thank you, Sonda.

Sonda: Yeah, thank you. You’re welcome.