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A Framework of Change For Successful Implementation of Medicare Part B Benefits

An overarching goal of NCOA’s Center for Healthy Aging is to strengthen and expand integrated, sustainable evidence-based program networks. A key strategy to accomplish this goal is to support aging services, public health, and tribal organizations across the U.S. in their efforts to achieve Medicare reimbursement for chronic disease self-management education (CDSME) programs. To break down this complex process into manageable components, NCOA has adopted a framework of organizational change with specific steps or stages of organizational change that are necessary to achieve Medicare reimbursement. These organizational stages of change revolve around five core programmatic elements: program delivery or implementation, accreditation (DSMT only), clinical supervision, billing, and documentation and tracking.

NCOA’s framework of change was adapted from the framework or model of change found in the Community Toolbox, an online resource made available by the University of Kansas. That framework describes a pathway of activities to achieve outcomes designed to build healthy communities and create social change.

Purpose

This framework of change tool is one of many resources that NCOA has developed to support community-based organizations as they work toward becoming viable providers of CDSME programs that are recognized by health plans and health care providers and have value in the marketplace. There is a two-fold purpose: 1) to define the organizational stages of change elements and the outcomes for each stage necessary to achieve Medicare reimbursement and 2) to map the key decision points within each stage of change that lead to the desired outcomes. A list of resources from NCOA’s website and other reliable sources are included to provide valuable information that can help with the decision making process. The focus is on three specific Medicare Part B benefits that offer potential to incorporate CDSME programs as a component of the service: Diabetes Self-Management Training (DSMT), Health and Behavior Assessment and Intervention (HBAI), and Chronic Care Management (CCM).

Implementation or Program Delivery

OutcomesKey Decision PointsResources

Implementation plan in place 

Necessary partnerships established to successfully implement the program and obtain referrals

Which Medicare benefit will be the primary focus of your effort: DSMT, HBAI, or CCM

DSMT Information Resource

HBAI Information Resource

CCM Information Resource

Where the program will be implemented, initially and potential expansion plansProgram Planning

 

Who the target audience will be
Determine the Leadership, staffing, and infrastructure (leaders, trainers, program coordinator, quality assurance coordinator, etc.) to implement the program

Sustainability

Best Practices Toolkit: Leadership and
Management

What partnerships need to be established to successfully implement the program AND to obtain referrals; Who your competitors and potential customers will be

Market Analysis Worksheet

Strategic Partnerships

How you will market your program to differentiate your services in the marketplace

Developing Your Value Proposition

Marketing and Recruitment Materials for CDSME

Best Practices Toolkit:  Marketing and Recruitment

Whether or not your organization will serve as the Medicare provider or partner with a Medicare provider (see also Billing below)

Medicare Payment Opportunities

Considerations for Becoming a Medicare Provider

 Accreditation (Applies on to DSMT)

OutcomesKey Decision PointsResources

Policy and procedure manual developed

Test class started

Test class completed

Accreditation application submitted to AADE/ADA

National accreditation/recognition from AADE/ADA

Will you apply for accreditation/recognition through AADE or ADA (Before you can bill Medicare, national accreditation/recognition by one of these two organizations is required. The 2017 National Standards for Diabetes SelfManagement Education and Support (DSMES) define quality, evidence-based DSMES services that are the basis for accreditation/recognition and meet or exceed Medicare regulations for DSMT.)

ADCES website

ADA website

2017 Standards for DSMES

Frequently Asked Questions

Identify qualified personnel (registered dietitian – RD— and paraprofessionals) to implement DSMES services and a quality coordinator to oversee the program design, implementation, evaluation, and continuous quality improvement activities (Note - The RD can serve as the quality coordinator.)
Ensure that personnel meet the training requirements (i.e., 15 CEUs for the RD and 15 continuing education hours for paraprofessionals and non-clinical staff) as specified by AADE/ADA and written position descriptions and resumes are on file
Who you will involve as stakeholders, and what roles will they play to promote quality and improve utilization
What are the barriers to and the need for DSMES in the communities that you plan to serve; how will your program address the needs of the population (consider language, race, ethnicity, culture, income, education, literacy); and who will you serve
Select and document the curriculum that you will use – DSMP originally developed at Stanford University – and how that curriculum is flexible and will be individualized based on each participant’s needs (e.g., documentation of each participant’s weekly action planning/goal setting)
How you will provide ongoing support and education for each participant 
How you will monitor, measure, and communicate progress of participants to providers
When and where your test class will be offered, and who will the target population be
Determine a primary site and any additional sites for offering DSMES

Clinical Supervision

OutcomesKey Decision PointsResources

Licensed clinician(s) committed to provide the service

NPI confirmed or obtained for each licensed clinician

NPI for each licensed clinician linked to Provider Transaction Number (PTAN) of Medicare provider

Decide how clinical supervision will be provided (i.e., existing staff, new position, partnership, or contractual arrangement) and how to locate a qualified clinician. (This will be specific to the Medicare benefit that is the focus of your effort)

For DSMT, how you will locate an RD

For HBAI, which clinical model to use: a licensed psychologist, nurse practitioner, or social worker (for Medicare Advantage only)

For CCM, which provider(s) to target to provide supervision (e.g., individual practice(s) or a management services organization (MSO), or do you intend to serve as your own provider (If so, your organization must have a nurse practitioner or physician assistant)

HBAI Information Resource

CCM Information Resource

What is the cost of the clinician to your organization, e.g. what are the going rates in your area, how much will you pay, how much time is needed to carry out the oversight and supervisionCenters for Medicare and Medicaid Services (CMS) Learning Network: NPI: What You Need to Know
What is your organizational process for negotiating with and obtaining a commitment from a qualified clinician to provide the service

Find out if clinician is registered with Medicare, i.e., has an NPI

If yes, enroll the clinician’s NPI with the appropriate Medicare Part B provider of DSMT, HBAI, or CCM

If no, register clinician for an NPI that is linked to the appropriate Medicare Part B provider

Billing

OutcomesKey Decision PointsResources

For organizations that decide to become a Medicare provider:

  • Applied for Medicare PTAN
  • PTAN issued

For organizations that do NOT plan to become a Medicare provider:

  • Medicare provider identified and in agreement to bill the services
  • Formal agreement (contract) signed with Medicare provider

For all organizations:

  • Billing processes established
  • Billing contract signed with third party entity if billing will be outsourced
  • Submission of Medicare claim
  • Reimbursement received
Weigh the risks and benefits of becoming a Medicare provider (Note - The Medicare provider is legally liable and must have appropriate liability insurance)Considerations for Becoming a Medicare Provider

Determine whether your organization will become the Medicare provider or partner with an existing provider to offer the Medicare Part B service(s)

If your organization will serve as the Medicare provider:

  • Complete the Medicare Part B registration process
  • Enroll in Medicare Advantage plans if they have a large market share in your area
  • Enroll as a provider in Medigap plans and Medicaid to collect the copayment
  • Purchase appropriate liability insurance

If your organization will partner with an existing Medicare Part B provider:

  • Explore options for which Medicare provider your organization will partner with
  • Initiate discussions and promote the value of your service
  • Negotiate a formal contract

Considerations for Becoming a Medicare Provider

HBAI Information Resource

CCM Information Resource

PECOS Online Portal (to register as a Medicare provider)

Sample Independent Contractor Agreement

Decide whether your organization will handle its own billing or outsource it to a third party billing entity

If billing is outsourced:

  • What will the process be for selecting the third party billing entity
  • Negotiate and develop a contract with the billing entity
 
Develop a billing process that meets HIPAA requirements and agree upon who will be responsible for what (Work with your interdepartmental clinical and administrative team to develop a step-by-step written process) 
Determine which claims will be submitted initially 
Develop a process to track and reconcile claims that have been filed 
What quality assurance measures will you put in place to monitor the accuracy of billing

Quality Assurance for Evidence-Based Programs

ACL/AoA Recommendations for Quality Assurance Programs

Documentation & Tracking

OutcomesKey Decision PointsResources
Documentation and tracking system established

What will your process be for documenting clinical information, tracking data, and reconciling billing in compliance with HIPAA

Will you use a paper-based system, an electronic platform, or a combination of both

If you plan to use an electronic platform, how will you select a vendor or integrate with a health care provider’s electronic health record. The platform should meet meaningful use standards)

Health IT Care Management System Vendor Selection Matrix
What will your quality assurance process be for monitoring service delivery and documentation

Quality Assurance for Evidence-Based Programs

ACL/AoA Recommendations for Quality Assurance Programs

This project was supported, in part by grant number 90CS0058, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.

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