Medicare Ups Provider Incentive for Prediabetes Intervention

Will pay up to $810 for 3-year program, with strict rules to prevent fraud

Participating providers may now receive up to $785 for each patient who loses 5% of their body weight and $810 if they lose 9% and complete other aspects of a comprehensive lifestyle intervention. Previously, the maximum payment was just $450.

The Medicare Diabetes Prevention Program (MDPP) offers frequent face-to-face sessions that teach diet, nutrition, and exercise strategies to high-risk beneficiaries. Diabetes costs Medicare $42 billion more than it costs for similar beneficiaries without diabetes, and the agency believes a program that can avoid some of that cost is worth trying, even if it doesn't work for some of the participants who enroll.

In another change to the program, outlined in a proposed Physician Fee Schedule Thursday, CMS would extend beneficiaries' participation to 36 months of face-to-face diet and exercise instruction curriculum; initially it was to be 24 months. The new rule offers two years of longer, ongoing maintenance sessions instead of one.

The payments are to be made incrementally to lifestyle instruction companies as beneficiaries increase the number of courses they attend, and as they lose more weight. Weight loss is associated with a reduced risk of progression to diabetes.

An estimated 20 million people age 65 and older have prediabetes, and nine out of 10 may not know it. The MDPP, however, may stimulate physicians across the country -- especially those in healthcare systems that are running the program -- to be more diligent about screening their patients for prediabetes. The program is said to be a big help to clinicians who complain they don't have time in their practices to counsel patients about the importance of lifestyle change. CMS plans to pay for MDPP services with no cost sharing on the part of the beneficiary.

Under the latest proposed rule, continued participation in the program after the first 12 months is contingent on participants losing at least 5% of their body weight from baseline, and keeping it off.

To date, some 1,450 companies -- from hospital systems and physician groups to wellness centers, supermarket chains, and churches -- have applied to the CDC to be a recognized MDPP provider. CMS said those granted "pending" recognition will be allowed to submit claims if they meet several requirements, such as submission of certain performance data on past MDPP-like diabetes prevention programs.

Eligible participants are those with HbA1c of 5.7% to 6.4% or fasting glucose between 110 and 125, who are enrolled in Medicare Part B, and have a BMI of 25 or greater, or for Asians, 23 or greater.

Thursday's proposed rule went into great detail about how the program will work, taking up almost 20% of the Physician Fee Schedule's 815 pages.

If approved in November, the rule would ... (please see next page)

If approved in the final rule expected this November, the rule would:

• Establish payments depending on number of one-hour courses participants attend (see table)
• Delay the program's start date from Jan. 1, 2018 to April 1, 2018 to give more time for organizations to prepare
• Allow beneficiaries who develop diabetes during the months they are participating in the program to stay in the program
• Refuse to allow the curriculum to be offered virtually, except as a limited number for make-up classes
• Create several "G" billing codes for providers to bill Medicare for incremental levels of each beneficiary's participation
• Permit organizations to offer "in-kind beneficiary engagement incentives" such as gym memberships, onsite child care or transportation, as long as they relate to the goals of the program, but not theater tickets or retail gift cards
• Prohibit programs from offering free meals or meal replacement services in the curriculum because they do not help beneficiaries make their own decisions to better manage their own health
• Allow programs to furnish participants with technological items for temporary use, such as a tablet loaded with fitness apps or a fitness tracking watch, as long as the total amount of the devices does not exceed $1,000 per beneficiary. Also, the organization must retrieve those items after the course is completed
• Prohibit giving participants technology items for their permanent use if their value exceeds $100
• Prohibit lifestyle companies from advertising incentive offerings. Companies must offer them after the beneficiary enrolls so as to prohibit selective bias in attracting beneficiaries who are more likely to succeed
• The proposed rule spells out an extensive number of fraud prevention criteria and oversight. It would:
• Require that organizations submit NPI numbers, birth dates and social security numbers for their lifestyle coaches that teach the classes. Coaches would also have to undergo background checks
• Prohibit coaches from program employment if they have had Medicare or Medicaid billing privileges revoked, been convicted of serious crimes including rape, murder, or assault, or financial crimes such as extortion, embezzlement, or income tax evasion, insurance fraud

"We propose that CMS will screen each individual identified on the roster of coaches included with the supplier's enrollment application to verify that the individual coach does not meet any of these conditions," CMS said in its proposed rule. "We have selected these types of felony convictions based on the risk we believe they could pose to the Medicare program and our beneficiaries."

Require that ownership change, changes in coaches, or adverse action history be reported to CMS.

Requires program applicants to pay a fee of $560 for program integrity efforts and to cover cost of screening.

Besides preventing diabetes, CMS says weight loss also can prevent sleep apnea, reduce risk of heart disease and stroke, and improve mental health and well being, according to the proposed rule.

CMS will take comments for 60 days. The final rule is expected in November.

last updated 07.14.2017

This article was first published on MedPage Today and reprinted with permission from UBM Medica. Free registration is required.