Many insurance companies allow physician to get reimbursed for the patient visit only if they see the patient face-to-face.

The dietitian can negotiate fees based on hourly wages or fee per patient initial visit or follow-up visit.

Pros:

• Flexible schedule
• Tax benefits for home office, equipment, utilities, services,
• Set own costs and fees

Cons:

• No show – no pay
• Responsible for everything
• Keep up on reimbursement issues and regulations
• No accounts-receivable department

Several states licensure statutes describe that a physician or a health care provider authorized to prescribe dietary treatments initiate a referral for nutrition services. It will be noted, therefore, that the referral of a qualified health care provider, such as a physician, is apparently an essential antecedent to the RD’s ability to practice dietetics or nutritional services of any kind. The statutes of some other states also contain references to a physician’s participation or supervision in the nutrition care process, but they are not nearly as restrictive as Alabama and California.

California State Regulation:

“[A] registered dietitian or other nutritional professional meeting the qualifications [of this statute] may, upon referral by a health care provider authorized to prescribe dietary treatments, provide nutritional and dietary counseling, conduct nutritional and dietary assessments and develop nutritional and dietary treatments, including therapeutic diets, for individuals or groups of patients in licensed institutional facilities or in private office settings.” Cal. Bus. & Prof. Code, § 2586.

Prior to initiating nutrition services such as medical nutrition therapy services, RDs should consider whether a referral is necessary or appropriate. A variety of factors impact referrals including payer policies that may be providing direct reimbursement to the RD, the extent to which state licensure laws may define the need for a referral, facility policies such as those addressing quality clinical care and continuity and the type of service being provided by the RD. [For more details, see the August 2008 Journal of the American Dietetic Association article, “Referral Systems in Ambulatory Care–Providing Access to the Nutrition Care Process.”]

For example, the federal government, under Medicare Part B, explicitly requires a “treating physician’s” referral for Medicare Part B–covered medical nutrition therapy services for diabetes and non-dialysis kidney disease provided by RD Medicare providers. There are instances in which private sector payers do not require a referral, as in the case of many disease management programs where MNT or nutrition services are included as part of the disease management program. In many of these cases, patients/clients qualify for the service based on their existing health condition, such as diabetes or obesity, which allow the patients/clients direct access to MNT services without the need for a physician referral.

Currently, only a handful of the 46 state laws that regulate dietitians or nutritionists through licensure, statutory certification or registration explicitly require a referral or physician order. Still, RDs should not assume that their state does not have such a requirement. Even in explicit cases, the referral language may differ in each state’s legislation.

Insurance Resources

• The assessment begins with an evaluation of the patient’s ability to consume food.
• The RD looks at current and past eating habits. A diet record completed by the patient or a family member is reviewed and discussed.
• The RD obtains a medical history such as weight and weight history, selected laboratory tests and medications that may affect nutritional status.
• The RD then examines the patient for signs of under- or over-nourishment; conditions that may affect swallowing, digestion, and the body’s ability to absorb or use the food eaten.
• Food intolerance and allergies; religious, cultural, ethnic, and personal food preferences; and diet prescriptions are also taken into account.
• The RD may also ask for information from the physician or other providers such as nurses, speech pathologists, and occupational therapists.
• The RD interprets all the information and designs an individualized plan of action including education, if needed.
• Two to three nutrition therapy sessions are recommended for optimal results.