Posts Tagged healthcare

Checking Benefits for Nutrition Counseling–How, Why?

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

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

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

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

How to check nutrition counseling benefits:

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

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

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

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



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Gender and Racial Diversity in Registered Dietitian Nutritionists

Edit: Updated statistics are available at a new link on the CDR website: Current demographics show 98,053 dietitians, 90.6% female, 3.8% male, 5.6% not reported, 77.8% white as of July 3, 2017.  Here’s a list of other credentials issued by the CDR and respective demographics.  The rest of the article will be based on the 2013 demographics.

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According to the Commission on Dietetic Registration’s demographic profile of registered dietitians as of December 1, 2013, 94.3% of RDs are female and 81.8% are white.

Interestingly, many health insurance companies declare network capacity by ‘number of dietitians’ and not the diversity of providers.  I know this because I have had to try very hard to get in-network with a number of insurance companies that have panels 100% of white females only to be told that there is no discrimination policy or diversity quota in place for providers.

There should be.  Patients should have a right to finding a demographic of a provider they identify with: whatever race, gender, religion, or sexual orientation that they feel comfortable with.  Not 100% white females.

You can check this by going to your health insurance provider’s website, looking for specialists, and then selecting nutritionist, dietitian, or registered dietitian, depending on how the profession is listed at your health insurance company.

Don’t get me wrong, white females do very good jobs at nutrition counseling, are fully qualified, and it shouldn’t matter.  However, many different types of people exist in the world, and healthcare can be much more effective if the patient identifies better with their healthcare practitioner.

Being able to choose the demographic of your healthcare practitioner can enhance credibility, trust, and the feeling of being cared for.  Even if objectively there is no difference in the credentials and education, there are subjective differences that it is politically incorrect to even mention but can affect quality of care.  And I’m not talking as a healthcare provider, I’m talking about patients’ perspectives.

Patients come from a variety of backgrounds, cultural, gender, geographic location, religion, sexual orientation, etc.  Healthcare practitioners cannot control initial biases of a patient that may make them discredit the information they receive.  It is a reality whether we like to acknowledge it or not.  Sometimes a patient may not feel comfortable bringing up a question based on who the patient thinks the practitioner perceives him or her to be versus who he or she actually is.

I am all for equal pay and benefits to women and men for whatever job they do. However, if we are going to talk about women in engineering (or any STEM field or law), it shouldn’t be taboo to talk about men in dietetics, a traditionally female field.

Interestingly, women in engineering represent a larger proportion, 13%, according to MIT news, of their workforce than the 3.5% represented by men in dietetics.  I once had a personal training client who went on and on about women in engineering and law, ignorant of the number of men in dietetics.  And who is to say one is more important than the other?  I was able to connect on the feeling of being a minority in a field, but I didn’t feel at liberty to talk about under representation of men in dietetics because it makes me sound like a ‘meninist,’ which is a shameful political view.

Reasons why men aren’t in dietetics?  Many of the jobs do not pay enough is one.  The median full time pay is around $50k/yr, and as someone who is in the field, I can tell you that it is 10-20k less in Austin unless you are a director of a major organization, you may make more.  Since becoming a registered dietitian requires a minimum of a master’s degree starting in 2024, seven years of education to make less money is probably not appealing to men, who are often traditionally (and sometimes still) thought to have to provide for a family and fund the cost of dating.  (Note the RD is a 5 year credential, 4 years for the degree in dietetics and 1 year of supervised practice; many RDs have much more education than the minimum).

But that doesn’t seem to stop men from going into fields like teaching, which has higher numbers than men in dietetics.  In fact, 23.7% of teachers of primary and secondary schools in 2011-2012 were men, according to the National Center for Education Statistics.  So something else must be the case.

Another reason there are fewer men in the profession could be the perception that it has traditionally not been considered masculine to care about calories, have soft skills like counseling, ability to comfortably show empathy, people skills that can elicit behavior change from clients, and ability to meal plan.

Traditionally, men don’t cook or bake as much as women in the home or take care of children, and there are many other skills that traditionally women are thought to be better than men at doing.  (Yes, there are excellent male chefs and stay at home dads, but I am talking traditionally).

Discussions on breastfeeding and/or pregnancy, often done at WIC clinics, are something women are naturally more expert than men at doing because they have the anatomy.

Additionally, there were certain things in the educational experience left over from when the profession may have been more like home economics or closer to working as a chef such as a class on how to set a table, appropriately garnish a plate, and other food service skills.  These may not be appealing to guys in their early 20s in college.

Nutrition science is what attracted me to the profession.  I love the science: nutrition biochemistry and exercise physiology.  Recently, I have also taken a penchant for counseling psychology.  I’m competitive against my younger self at getting people to make changes with regards to their health and well-being in how I implement education and counseling.

In addition, private practice pay is based on how much business you want and how well you market and get client success.  As a competitive person, this is motivating to me.  Whereas working full time, possibly changing people’s lives, and getting paid less than the median expected pay in the profession while not having freedom to practice how best helps patients is a reason not to work as an employee in this field.  That is not motivating to me.

Are men openly accepted in this field?  In some ways yes.  I can tell you that a number of clients have specifically come into my office because of my gender, overtly stating they wanted a male.  I think I may bring in clients who normally would never see a registered and licensed dietitian.  I think diversity in the profession would only help more people to know what we actually do by bringing in more types of people who normally wouldn’t come in.

In MANY other ways, there was a lot of unjust discrimination I endured going through the education and training process of becoming a dietitian (and after becoming one) that, because of aggressive feminism (not true feminism, which is about equality of genders) and/or others’ projections about men, I felt unable to even be allowed to voice opposing viewpoints because it wouldn’t be considered politically correct and fall on deaf ears when 3.5% of the profession is male (much like I stated above, where men represent a smaller percentage of dietetics than women do in engineering).

In fact, I don’t even feel free enough to voice it on this blog.  Suffice it to say, after years of being underestimated and written off as a ‘stupid man’ (quoted, a supervisor during my internship stated under her breath) who couldn’t begin to understand the intricacies and emotions involved in nutrition counseling, it motivated me to start my own private practice because, yeah, I do know what I’m talking about. I feel competent to counsel individuals independently about nutrition and nutrition/exercise-related healthcare.  I certainly have gone out of my way to get the credentials and experience to prove that.

Unfortunately, I don’t have a professional counseling credential behind my name, but I have been to therapy for over 6 years (at time this is written) going twice a week in a group and individual setting and am very familiar with counseling skills having worked through my own issues and seen others of a variety of different personalities and backgrounds work through theirs.  And I’m out about that because I’m proud about it and hold my hat off to the various counseling professionals who are so good at what they do (and I do work with them–my office is surrounded by them!).  I know when to refer patients to seeing a counselor when it is beyond my abilities, which is what our code of ethics states we should do.

Back onto differences between men and women:

Men and women write and emote differently (or if looking at masculine vs feminine gender expression, there is a masculine and feminine way of writing and emoting).  If you are a man (or a woman who writes like a man), chances are you don’t write with many exclamation points in your emails, emoticons, and attempts to influence the recipient’s emotional response of your email.

In dietetics, the female manner of writing is expected in emails.  Our dietetic practice groups have explicit netiquette rules that state that anything that has the effect of disparaging any individual is inappropriate, too terse, bossy/demanding, and abrupt.  While ‘alternative points of view are encouraged,’ they really aren’t.

If you have an alternative point of view, it can have the effect of disparaging an individual if they wish to view it that way, and thus the email is inappropriate because it can feel critical on the way others practice.

I feel, as a man, if I don’t attempt to really spend time on my emails and make them less succinct, well good luck winning friends and influencing people in the profession.  And it’s not like I don’t have other things to do during the day.  It takes a lot of time to write emails in an attempt to not hurt any of the 89,300 people’s feelings in our profession and how they might misinterpret what I wrote and take it offensively.  Well guess what, as a man, I automatically am much more likely to offend someone in our field because of my gender because men are perceived ‘forceful’ in any opinions we have.

While it might be thought of as confidence and life experience in an older woman, for a younger man, it is considered arrogance, regardless of whether I actually have that confidence and life experience.

As someone who went to an all male Catholic school, I was not taught to write in a deferential manner.  I was taught to write to get my point across.

I understand that women’s rights are still not on the same level as men’s.  But to be a scapegoat for all the angst of women by being a male in the profession, that is the job of being a man in a 94.3% female profession (notably 2.2% of the profession didn’t declare a gender, so perhaps we have 2.2% transgender individuals).  I also am expected to behave up to a standard women in the profession don’t hold themselves to (many who don’t follow the code of ethics themselves).  I have personally received emails from multiple other dietitians telling me how to act since becoming a dietitian, both with the ‘tone’ of encouragement and with the ‘tone’ of attempt to control my behavior.

Even when going through my internship program, most of the members of my internship class went to a women’s conference together.  I was not invited or thought of.  I was left out on purpose.  Let’s suffice it to say I didn’t feel part of the group or welcomed.

Enough on gender differences though.  I digress.

There is a great need for more racial diversity within the field of credentialed and practicing licensed dietitians in addition to more gender diversity.  People who need nutrition services come from a wide variety of cultures.  Who better than a practitioner who is trained in the profession and comes from that culture to help people from within the culture?

As much progress in civil rights as there has been in the last century, it isn’t enough.  People of different races deserve the option of a healthcare practitioner of the same race to avoid unsaid prejudices from either side.  Prejudices still exist and need to be acknowledged.

Cultural competence is taught in dietetics education, but it is not enough.  We cannot control a patient’s biases as practitioners, and for the sake of a patient, he or she needs to have the option to choose a practitioner with whom they can at least have confidence fewer assumptions of bias are happening from either side.

Dietetics education programs should be making it a top priority, for the sake of the credibility of the profession and ability to have an impact on more people, to be inclusive of men and non-white racial groups.  An effort needs to be made to make the profession more appealing to minority groups and diversify the profession demographics.  Insurance companies should also have more diversity within their practitioners.  It is unacceptable for 100% of a list of specialists to be white females and that the insurance companies are ok with this.



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Telehealth and Nutrition Counseling in 2017

The Centers for Medicaid and Medicare Services (CMS) recognizes the place of service code ’02,’ which allows telehealth as a place of service.  Codes licensed dietitians can use to bill insurance include 97802, 97803, and 97804, which are recognized as billable with telehealth according to the CMS website.  Other codes can be seen in the same link (if you are a healthcare practitioner reading this who isn’t a dietitian).

Certain requirements must be met, including using secure software for teleconferencing up to HIPAA standards, an approved originating site, and being an approved distant site practitioner.  According to the CMS website on page 2, an approved originating site can be a physician or healthcare practitioner’s office, which means wherever the practitioner defines his/her office, the telehealth requirement can be met.

Other approved originating sites include “hospitals, critical access hospitals (CAHs), rural health clinics, federally qualified health centers, hospital-based or CAH-based renal dialysis centers (including satellites), skilled nursing facilities (SNFs), and community mental health centers (CMHCs).”

Additionally, the same previously mentioned link also states registered dietitians or nutrition professionals, depending on who is allowed to practice in your state and receive insurance reimbursements, are eligible practitioners to furnish telehealth services.

Other non-dietitian distant site practitioners can be “physicians, nurse practitioners (NPs), physician assistants (PAs), nurse-midwives, clinical nurse specialists (CNSs), certified registered nurse anesthetists, clinical psychologists (CPs)*, and clinical social workers (CSWs)*.”  *CPs and CSWs have limitations.

Unfortunately, dietitians in private practice can only perform telehealth services if the beneficiary (the patient) is at an originating site.  This means patients must still go to their healthcare practitioner’s office to receive the service.  Private payers (non Medicare/Medicaid insurance) may have their own rules, but often Medicare is the example.

 You should check with your private payer for their rules if interested in telehealth over traditional face to face services.

Real time communication, as opposed to delayed communication like email, must be used unless in Alaska or Hawaii.  If billing, a modifier ‘GT’ or ‘GQ’ must be used.  The former states that the service was done “via interactive audio and video telecommunications systems” whereas the latter states it was done “via an asynchronous telecommunications system.”  (same reference link above)

Both the originating site and the distant site practitioner receive payment.


While it is important that communications remain secure, I had hoped telehealth would be implemented in a way that could save healthcare costs and improve access.  Since the originating site must be one of the aforementioned sites (assume for security, not sure), telehealth is still not as convenient as it could be.

A patient must still go to an originating site rather than being able to have the service done via webcam from the convenience of their home or their office.

On the plus side, distant site practitioners can partner with the aforementioned healthcare originating sites to provide covered services.  This DOES improve access for people in rural areas who may not have as easy access to specialists who are allowed to receive reimbursement for telehealth.

At Nutrition and Fitness Professional, LLC, we are available to work with healthcare practitioners who wish to refer their patients via telehealth for medical nutrition therapy (codes 97802, 97803, 97804) and use Google Meet as our secure HIPAA compliant video conferencing platform as well as other G Suite approved HIPAA compliant apps.

It is not necessary for the originating site to have access to G Suite in order for the service to be performed as the client only needs to click on a Google Calendar link.

For specific questions, please contact us.



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Repeal of ObamaCare and Possible Effect on Your Nutrition Counseling Benefit

At the time this is written, it is still too early to tell whether or not the replacement for the Affordable Care Act will result in the loss of coverage for preventative healthcare services or not.  President Trump has stated that some parts of the healthcare law will remain.

What worries me, as a practice and business that highly uses insurance-based nutrition counseling benefits, is that the loss of the mandate will mean insurance companies could cut their coverage for the services I do unless you have a formal physician referral for a specific medical condition.

Currently, most people do not know (and your insurance company is very evasive in letting you know) that you MAY (about 80% of my clients) get 100% coverage before you even meet your (enormous) deductible for preventative nutrition counseling, unless you have a grandfathered plan from before the Affordable Care Act.

Specifically, I can use a preventative code as a dietitian for preventative services with many insurance plans that results in no copay or coinsurance (yea, too good to be true, right?).

As a licensed dietitian in private practice, I am not allowed to diagnose any specific medical condition and am restricted to using a preventative code or a BMI code (because it is a calculation) to support coverage for nutrition counseling.

This allows individuals to just see me to work on their health rather than having to go do extra work and get other diagnosis codes from their physician, which may be subject to copays, coinsurance, your (huge) deductible, and cost to see your physician for the diagnosis (which also costs money!).

If ObamaCare is repealed, then I sincerely hope that the clause that allows coverage for nutrition services (CPT codes 97802/3/4 medical nutrition therapy) with a preventative ICD-10 code remains for a few reasons:

  1. Individuals who are overweight or obese without a formal diagnosis of a comorbidity (medical condition) face a financial barrier to getting on track with the professional who can literally reverse their condition without drugs or surgery.  Removing this barrier can be a huge boon to getting people in the door who need to work on themselves before they use a cop out excuse like “it is too expensive.”  Individuals WANTING to make a change to their diet and exercise habits needing legitimate information need all the support getting into my office they can get (a whole other blog post on the swamp of misinformation non-degreed fitness professionals give out about weight loss that you probably already self-pay for in personal training sessions).
  2. America pays more for the disease than the prevention.  Small fires are easier to put out than blazing forest fires.  This is a metaphor to saying overweight is easier to treat than type 2 diabetes, surgeon fees for coronary artery bypass, chronic kidney disease dialysis procedures, and pharmaceuticals for band-aid-fixing diseases that can be cured with lifestyle change.  Supporting the healthcare professional, through health insurance, that facilitates lifestyle change is supporting a registered dietitian and exercise physiologist (me).
  3. If my practice dwindles due to the repeal of the Affordable Care Act, I promise you that isn’t because everyone is healthy all of a sudden.  It is because there would not be coverage.  Even though the price of my services is inexpensive compared to what your surgeon or primary care physician costs, many people feel they are already paying for healthcare with their premiums, so they should not have to pay a dime more.  One of the major ways to have more coverage for services is if your premium is higher, to my knowledge.
  4. Loss of coverage for nutrition services would be a step backward in fighting many of the health problems that are easily treated by diet, exercise, and lifestyle changes.
  5. In appeal of Trump’s love for small business owners, as a small business owner, I have spent my blood, sweat, and tears slaving over my private practice for the past 3 years learning how to facilitate coverage for my services through health insurance for the benefit of helping clients and making a living myself.  By no means am I getting rich doing this.  I still work 7 days a week with a part time job seeing clients with my business and through an employer.  I have good success with the clients I do see (they let me know, or I see it myself).  I deserve to not have what I have built over 3 years burnt down just through a change in government administration.  I deserve to not have the rug pulled out from under my feet.  Not enough people are even using the benefit yet, nor is it advertised well enough through your health insurance company (probably because they think they lose money in the short term).

I agree the healthcare law is not perfect.  As a small business owner who is single, male and over age 26, I pay for my own health insurance through the Exchange without a husband or wife with a full time job with benefits a spouse can get on.  It is one of my biggest expenses next to paying for office space in Austin.

However, I also realize that as someone who is extremely fit, healthy, and barely uses his health insurance for anything except my flu shot and annual physical, I am paying for others who are not as fortunate as me to have the knowledge I do about nutrition and exercise and the desire to live the lifestyle.  And I’m fine with this.  I have no issues with it.  I can budget my money well if others need to use their health insurance more.

I know other young people are not aligned with this idea, and I do see the opinion that they feel they pay too much in premiums for something they don’t use and that as healthy people, they shouldn’t have to foot others’ healthcare bills who don’t care as much about their health as they do.

Clearly this is a complicated issue, and it is good that people can stay on their parents’ health insurance until age 26 and that 20 million more people actually have some coverage, but Americans also do not like paying for each other’s healthcare, and that is also a valid opinion.

I urge you to reach out to your representatives and senators with your concerns about the healthcare law reform.  If you are reading this post, you might care a little about preventative healthcare coverage and/or nutrition counseling coverage.  Please don’t be silent during this time when our voices need to be heard.

When it comes to nutrition counseling, Americans deserve legitimate information from a trained, degree-holding, licensed professional who is an expert on the subject and adept at working with individuals and groups.  Americans deserve the right to avert disease before it starts.  Americans deserve the right to prevent further healthcare costs down the road by taking action to a healthier lifestyle now, and they do not need additional financial barriers put in the way merely as a way to myopically cut costs and keep campaign promises.  Long term, it does not save.  Long term, we lose.

Yes, if you cut nutrition counseling, health insurance companies will save a little bit of money now.  But if you cut nutrition counseling long term, disease rates will go up and healthcare costs go up.  Clearly this is not a simple issue and needs to be considered carefully as a new healthcare law is implemented.

Edit 02/07/2017: A professional colleague alerted me to former President Obama’s recent article published in the New England Journal of Medicine on the possible repercussions and irresponsibility of repealing the ACA without a better replacement that is openly discussed first since posting this yesterday.

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