Insurance billing and reimbursement is a complex topic that can be difficult to navigate. This week Dr. Sandi discusses recent changes to Medicare and Medicaid billing that affect health coaches in 2024. She is joined by FMCA educator and insurance billing expert Sonda Kunzi of Coding Advantage.
If you are new to medical billing or want a better understanding of how it affects health coaching, follow along. Sonda covers the basics of the three billing categories, how health coaching currently fits into these categories and potential future changes for our industry. What’s more, Sonda discusses different ways health coaches can work with physicians to potentially be reimbursed for their services.
- Understand the CMS changes to Medicare and Medicaid for 2024 related to health and well-being telehealth services.
- What are the different insurance billing categories and what do they mean?
- Learn how health coaches can potentially get insurance reimbursement.
- How to use this knowledge to sell your services and partner with physicians.
Meet the Guest
Founder of Coding Advantages LLC
With over 30 years’ of experience in all aspects of the business side of healthcare, Sonda Kunzi built a successful healthcare consulting and billing company with over 30 team members. She enjoys working with providers and healthcare organizations to find the right way to be reimbursed for services. She has personally worked with hundreds of clients analyzing organizational processes to find ways to leverage staff and workflow to decrease operational costs and increase reimbursement.
Sonda has a good understanding of the functional medicine approach to healthcare and has worked with many providers and groups who want to run a hybrid practice managing both membership and insurance reimbursement contracts. Understanding how providers need to concentrate on patient care but still want to understand the concepts is my superpower.
Dr. Sandi: …to “Health Coach Talk.” Listen up. This is a very special episode. It’s something that I know you are all interested in, have a lot of questions about, and that has to do with insurance reimbursement for coaches.
And that’s why I have as my guest today, Sonda Kunzi. She is running Coding Advantage. That is her company, and she is the real guru. Whenever I have issues about insurance reimbursement, she is the expert that we turn to. She teaches for FMCA, and so I’m so glad that she is here with us today. Welcome, Sonda.
Sonda: Oh, thank you so much. You know I love this subject matter. Hopefully, you’re planning on talking about all the latest news that just came out.
Dr. Sandi: We are, so let’s dig right in. Hot off the press was the announcement from CMS, and that is the Centers for Medicare & Medicaid. They announced that, on a temporary basis, they are approving health and, they call it, well-being coaching as a telehealth service for 2024 as of January 1st. So, here we are in 2024. So, Sonda, what are your thoughts about this?
Sonda: I wish I could be a little bit more joyous about that particular announcement. I think it is in the right step, but I really want everyone to know that I have seen a lot of publications come out popping up from places that I don’t really know but maybe they have helped coaches in their area in the United States or whatever. But that was a big misnomer about automatic reimbursements for 2024. And I’m sorry to say that I have not seen the reimbursement come clearly out from CMS. Not only are we going to make this a telehealth, but we’re also going to endorse it as a service.
So, from a health coaching standpoint, right now, it has remained in Category III, which just means it’s not Category I that would automatically be assigned an RVU. There may still be opportunity to, again, negotiate with insurance carriers, although I want to say that’s far and few between. And there may be some places out there that say, “Oh, yeah, we’ve negotiated this,” and that’s great. It depends on your location of where you are, your relationship with the payer, your proof of, you know, the value-add to them.
And sometimes it’s going to be part of a value-based payment where it’s included and that’s the expectation of the insurance carrier. But right off the bat, we do not have a new CPT code for the health and well-being coaching that is going to reimburse. Yeah, that’s the news.
Dr. Sandi: Yeah. So, that is the reality. And here’s my interpretation, and that is to see it as a positive sign that CMS believes in health coaching. It may not be to that final step. It may take years it may happen down the road, but it’s an endorsement of the profession that at least it came up. And whereas, years ago, that never would have been the case.
Sonda: I have to agree. So, we have to sit back and say, “What prompted that announcement?” That’s the question, guys. I mean, we really have to ask. And I’m not going to say I know what that was because I don’t. We saw a lot of my fellow consultants and people that I talk with in the business were like, “Where did that come from and why was it on their docket to say it?”
So, I think that, yes, we can have an absolutely… What do I want to say? The approach can be, “This is great,” right? The problem is it didn’t correlate with reimbursement. And unfortunately, some people who may not have known right away did do some… I actually Googled it just to see, and I saw some that says, “Oh, health coaching is going to be paid for.” And I’m concerned about that because then that, kind of, puts the health coaching I think behind the 8 Ball, and they’re talking to providers, and they don’t know the real story because there are ways to get reimbursed.
So, we hit that Medicare thing.
Dr. Sandi: Let’s talk about that. Yes.
Sonda: On that note, right?
Dr. Sandi: Yes.
Sonda: We did hit the Medicare thing, which was not right now is there a set reimbursement for the Category III code. So, we know that the national health coaching, health and wellness societies and associations are there lobbying very heavily on behalf of all the coaches.
When I think of all the healthcare services, I have heard the most about the work that’s being done on this. So, that part’s, I think, very important to health coaches in the future, and wondering what does the future hold is there are so many people lobbying on your behalf right now. And it’s, sort of, like you’re not going to change the elephant in the room immediately. It’s piece by piece by piece.
And here’s another piece. It may not be right on reimbursement, but it was somebody recognizing that it could be a telehealth service. That’s basically what CMS was saying is that, “Oh, okay. You know, so that put it out there, that if you have already negotiated something on the behalf of that insurance carrier, that you can do by telehealth now.” So, again, we’re going back to on that note. I can go off on a tangent. Anyway…
Dr. Sandi: But before we go over to the good news about getting reimbursed, for those who may not know what a Category III is, can you just explain Category III versus Category 1?
Sonda: I would love to. So, in the world of coding and healthcare services, that is… Oh, everybody knows that it’s… I think everybody knows, but if you don’t, let me tell you. The association that oversees that is the American Medical Association, the AMA. So, they attach codes to certain services to identify those for potential reimbursement. And there are three categories, Category I, Category II, and Category III.
Let’s start with III, because III is the entry point. Category III codes where health and well-being coaching services are currently are recognition. These are recognized services that are new, emerging, are showing providers and insurance carriers and people in these associations that these services have a positive impact to patients’ health and well-being. So, they created this. When these codes came out, I was completely in shock because I knew that for years and years and years, we didn’t have anything. And to get it to a Category III was a big deal.
Now, once it sits in Category III, we want to make sure, and I’ve said this before, that even if there’s zero dollars attached to it, if you’re doing this service, and you at least want to get it out to the carrier with reporting codes, you want to do that. You want to get those codes out there so that they can see and recognize it through claims because that’s how they’re looking at it, how often was the code used, and folks don’t know that. So, that’s Category III.
No, what we know is a, relative value unit, means a value that goes to reimbursement, will ever be assigned to Category III unless a carrier recognizes it. So, it still leaves the option open for a carrier to determine the reimbursement value of that particular service.
Category II codes are codes for quality. They’re just reporting quality. I did a hemoglobin A1c every three months. I did patients’ blood pressures. We measured this or we measured that. And they’re pretty standard throughout all of medicine.
And then a Category I code is where we want the health coaching to go, right? So, Category I code means that I’ve graduated from III. I have proven that this service is going to continue and remain in the mainstream healthcare, and then it starts to get relative value unit dollars assigned to it as a reimbursable service.
So, Category III was the first step, and then it’s going to go to Category I again. Just quickly on Category II are quality measure codes that never have a value to them. They’re just what happens with some value-based care, measuring blood pressures, weight, what have you.
Dr. Sandi: All right. Well, I hope that that clears it up. And let’s now get to the real exciting part. What are you seeing out there? How can a health coach get reimbursed? Let’s say they’re working for a practitioner’s office, and I assume that we are talking about having that practice bill as opposed to an independent coach running their own business, submitting a claim.
Sonda: Yeah, there’s a couple ways, right? So, let’s talk about insurance reimbursable real quick. Under a provision called “incident to” which means you are working under the direct supervision and, in some instances depending on the code, general supervision. We’ll hit that pretty closely in a minute here. The service can be built under the physician, the nurse practitioner, or a physician assistant with the actual services being provided by a health coach.
One of the big ones we had out there that we’ve talked about for a couple of years is remote patient monitoring. So, remote patient monitoring would be that the patient themselves has some condition. Now, clearly, remote patient monitoring doesn’t have to be chronic but it’s typically a chronic presentation, right, which is usually the case. When we’re bringing in health coaching, we usually have somebody who’s diabetic who needs to be turned around. They might have high blood pressure. They have the underlying problems where… Well, health coaches are made to help change that behavior, right? They’re not diagnosing, they’re not prescribing any medication. They’re helping change behaviors.
And let’s be honest, that’s what has to happen at the core of a person in order to finish out their journey of healthcare recovery. We’ll call it recovery because it’s a recovery from having certain habits and building in healthcare in the manner that they do. And usually we’re helping them get off medications and things like that.
So, remote patient monitoring… Let’s take an example. Let’s have your patient who is a diabetic might have a glucose monitor on, and remote patient monitoring would be this… And I’m just reminding folks what those are without going in in our little tiny segment here and all the codes. It would be setting up equipment. The provider orders it, so it’s a physician order. There’s a setup of equipment, and then there’s monthly monitoring. And there’s many companies out there who do the monitoring.
But the health coach comes in after the order, the physician gets it set up and they say, “I need you to watch this,” right? So, not only are they looking at the responses and the data… And, again, I don’t want to put any heavies on anyone. It doesn’t mean that you have to know when things are out of whack, right, because there are parameters that get set up and you’re working closely with your providers. What you’re looking at and what you’re doing is reaching out to the patient, “How are you doing today? I noticed your blood pressure was up,” or, “Your sugar was up. What did you eat? What did you do?”
Basically what we’re doing here and for remote patient monitoring to work is patient engagement. And that is a strong suit of health coaching. We have to get the patients engaged in their care. So, remote patient monitoring is one of those ways. So, if you don’t know a lot about that, do some research and we can always circle back and do a special one just on that. But this is a monitoring system of a patient being on a piece of equipment, whether it’s testing their glucose or maybe doing blood pressure. There’s a weight… You can get into the weight thing and things like that. That is one way.
Another way is chronic care management. Again, this is another patient engagement. These things are not able to be lifted off. And I’m going to tell the health coaches here that one thing I want you to remember is that these offices with physicians, the resources they have internally with their medical assistants or their front desk people and all that, they don’t have the kind of time to dedicate that a health coach can. And then the step two of that, just being the health coach who does that, is the time that you’re actually engaging the patient and having that impact to the behavioral piece of it and, in the end, is having the positive impact on the. chronic care.
So, those are two of the major things that we’ve talked about a little in the past that haven’t changed, that are available to health coaches to get involved with their providers to be this quarterback and really have a tremendous impact on patient engagement of that program that they normally would not be able to lift off.
Dr. Sandi: Is the chronic care management…so, that can be either Medicare or the private insurers?
Sonda: Yeah, so it’s a payer to payer thing. You just have to know which pairs pay for it and which do not. And for the most part, I’d say 90% of them do. The only time we see any real issues is if the insurer has put in a program themselves. And we do see a lot of that, by the way, where the insurer has the corner market. They also have their own program. And so that would be the only reason. But Medicare is the big driver and most of the major carriers do.
Dr. Sandi: So, just to be clear, I’m a health coach. I’m working in a doctor’s office. And so the billing is under the provider’s name, license, so it’s assumed that the health coach is actually performing the session. They have the encounter with the patient.
Sonda: Mm-hmm. Yeah. And what we need to be clear is this is under what we call an “incident to” provision. That is under supervision. It is clear for remote patient monitoring and chronic care management that is general supervision, which is a little bit different. It’s direct [inaudible 00:15:26]. The provider’s right there in the office. You perform it in the office. General is you don’t have to have that. It’s just the provider ordering the service and the auxiliary personnel, is the words we use for the health coaching, carrying out the orders. So, that’s how we… Correct, the bill would go under the physician in that case.
And there are certain provisions and rules that you have to follow, and you just want to make sure that you do. Make sure all that is in place. And still, again, it’s about providing the service, having the impact on the patients, and trying to have ultimately an impact on healthcare at the chronic care level.
Dr. Sandi: Mm-hmm, absolutely. So, I think that is something that would really behoove coaches, who want to work with doctors, to map this out. They may not realize that that can be reimbursable, and it could be a way that they can afford to have a health coach in their practice. Can you comment on a group medical visit? Do you see that as a growing model? We’ve talked about that in the past. Is there a way that health coaches can be the educator for the group? And anything that you see there that you’d like to comment on, any changes, for example, in the requirements for reimbursement?
Sonda: Yeah, I have not seen any big changes in this. So, we had talked about this a couple years ago as a shared medical appointment, an SMA. Some people will see it. And the health coaching…it’s a way of leveraging health coaching education during a virtual session with several members of a group and the provider billing for the services when they see the patient, which is usually you take them out of the group session, see them individually and bill like that.
The leverage of the health coach is, in that group, providing the education, creating the community while the physician or the nurse practitioner does the evaluation and management work. I think I want to caution folks that that can’t be a gigantic group because you can’t physically get all those people out. The impact there that providers need to know is this is like an ancillary add-on great service that you have a health coaching providing this group in this community of people with like problems, and then you’re able to do virtual meetings where that would be billable if everything is met, especially with the changes that came with the evaluation and management codes for the physicians.
In 2021, we had a big change that allowed some things there. And I haven’t seen very many groups take this on, but I am seeing I’d say more than in 2021. So, I’ve been talking with folks in the background. I think that people find it difficult if their group gets too big. So, my advice is create more than one group. You don’t need to have everybody in one group.
Dr. Sandi: That is absolutely correct. Well, I know from running many groups when I was a clinical psychologist, that the sweet spot is about eight. Ten would be pressing it. And this can be virtual. And I know you had spoken about it, and our virtual friend, Tom Blue, talked about it. You can have the breakout rooms in a HIPAA-compliant Zoom for the evaluation and management session. The coach is facilitating the big group, but big might be 6 people, 8 people, 10 the most might be on that. It gets a little difficult, but if this is a group where people really want to share experiences and get a lot out of it and participate, I think that the smaller group is good. Although I’ve had groups where we had one person show up, and so it became a one-on-one session. So, one person makes a group, a group of two, so not to be discouraged. But it’s good to hear that this grew year over year. And I have big expectations. And for coaches listening, this is a wonderful way that you can go into a practice and offer groups. And, yeah, you can come into several practices, and contract for your services, and facilitate, and show these practitioners the model. And perhaps a nurse practitioner can lead those sessions.
Sonda: Mm-hmm. Yeah, absolutely. And I think that really what we see a trend in healthcare, and I’m sure you’ve seen it too, is that it’s community. We are trying to build communities to take care of people. And I think health coaching fits right in that niche where they’re trying to have a positive impact, they’re trying to motivate patients to make changes in their life, and I think that’s a huge sell to physicians, groups, clinics to say, “I could build a community with my patients so they stay engaged in their healthcare, and we can get them better that way.” And it’s also a nice way to say, “I go to my physician’s office, and I also am part of a group he has with health coaching.”
I think that too many of the society is tired of trying to be, I hate to say it, a cattle call. Go to your physician, you leave, you hardly ever talk to them again, you can’t get them on the phone. Building that community and providing that buffer between the physician and the patient when they just don’t have time to be that close to them is really something that they could offer to having health coaches.
Dr. Sandi: So well said. I could not agree more. Where you’re running groups, the community is the medicine. And our healthcare system has become so impersonal and so stressful, patient burnout from navigating—trying to get an appointment, long waiting lists. You’re stuck on hold, and then you get disconnected. Your physicians are in a big hospital system. They don’t know you. You have long waits in the waiting room. You don’t get your questions answered when you finally do get that consult. So, this is a way to bring the human touch back.
So, for that shared medical appointment, just to be clear with that, is that Medicare that has reimbursed for this, for those E&M visits with the doctor that are in those breakout rooms as well as private carriers might as well?
Sonda: Yeah, so Medicare did come out, and there was a publication years ago where they said that, as long as the guidelines were met, that they didn’t see anything wrong with it. It’s some letter, I can’t even reference it at the moment. Sorry. But, yes, insurance carriers themselves have come out. Some have, either they have it clinically out here they put a publication out and say, “Yes, it’s okay if…”
Generally speaking, what you’re going to hear is, yes, it’s okay if all these things were met. So, that’s the part we have to make sure that we do and that we teach our providers that the best thing is that the health coach continues, and the education, and the group, and the community-building, and that providers still get the one-on-one that they would, doing telehealth one at a time anyway on a schedule, and then the patient gets the benefit of having that group session otherwise.
Dr. Sandi: Yeah, it’s a real win for everyone. So, the practitioner has their 8-10 minutes, which we do anyways if it was a one-on-one consult, and then the patients have the benefit of having that group. And they’re driving the agenda, and they’re telling the coach, “We want to work on quieting meditation techniques,” or, “We want to learn about healthier food, how to shop in the grocery store, how to read labels.” Whatever they’re interested in, the coach is the educator, facilitates that discussion. It’s a real win-win for everyone.
So, anything you see on the horizon? Anything that you have noticed where you’ve said, “Oh, yeah, this is another way that health coaches are being integrated into practices and can be potentially reimbursed”? Anything else you’d care to comment on?
Sonda: Yeah, I think we’re starting to come towards that direction. There is things now coming to light in terms of let me just take this from a little bit of the mental health side that we’re seeing the providers that are certified and that being recognized by Medicare. And I think this all kind of goes together.
So, we were only seeing licensed people recognized by Medicare at certain independent licensure, and that may be the case. Now they’re talking about an education level and a certification. I think they’re just starting to open the doors to just other types of providers instead of our traditional.
So, I, kind of, see us going in that direction and some of the things that they’re offering in terms of the integrated behavioral health. And there’s this new one called the principal illness navigator. That might be one where somebody’s really chronically ill, we might be able to get somebody taking care of the patient. That’s very similar to chronic care management.
So, I don’t want to put those out there as exact health coaches thing, but what I see is trending, things that are trending that they’re paying for services outside of the office or in group settings or in, again, people who are certified to provide care with certain skill levels.
Dr. Sandi: Well, that’s why I love you, Sonda, because you have your finger on the pulse of the insurance reimbursement world. And these things are changing all the time. So, by the time we air this…
Sonda: It might be different, right?
Dr. Sandi: …it might not be the same information, right? There’s always that caveat when we talk about insurance, that these things are subject to change. It all depends on the particular carrier, the deductible, as you and I know, that there are… Because something’s on the books doesn’t automatically guarantee that there will be payment. But we really applaud you and your level of expertise and the benefits that you bring to our FMCA community, sharing all of your knowledge and experience. So, where can people find you?
Sonda: Well, we definitely have a website. I have a website out there. It’s just www.codingadvantage.com. We’re trying to get some presence on obviously Instagram and Facebook and things like that. So, I think that what I would want to tell everybody is that we’re looking, again, to help integrated medicine providers and health coaches find their way through. It may not be something that’s super billable, but if you have questions that we can answer for you, we do have a contact form on our website. I’ll be happy to try to answer any questions anyone has.
We also have a free 15-minute consultation for anyone who’s really seriously trying to say, “I really want to market myself to a provider. Maybe you can give me a few extra words in a free little consult meeting.” So, I’d love to offer that to folks.
Dr. Sandi: That would be very, very helpful. Well, thank you for taking the time to talk with us. So much knowledge.
Sonda: Thank you.