I’ve heard a lot about how CBOs might be able to tap into Medicare reimbursement for certain services. What is the latest on that opportunity?

You’ve heard correctly! While Medicare billing has not traditionally accounted for a large portion of CBO revenue, and few CBOs have had mechanisms in place to tap into this payment stream, that is changing rapidly as new Medicare codes and a proliferation of value-based payment reforms are incentivizing the kinds of preventative and community-support services CBOs provide. These new policy developments have opened up opportunities for CBOs to more fully integrate with the health care sector—and get paid in the process. Please see below for a high-level overview of issues related to CBOs and Medicare.

  •  Most of the current CBO Medicare reimbursement opportunities are available under Medicare Part B, which covers physician services, office visits, screenings, therapies, preventative care, and other outpatient services. Learn more about Medicare Part B on Medicare.gov.
  •  A Medicare Provider number is the key to being able to bill for services. A CBO can either go through the process to obtain its own Medicare Provider number to bill directly for some services or partner with an existing provider that has its own Medicare number to receive reimbursement. Different benefits have different rules for who exactly can bill Medicare directly. Learn more about whether becoming a Medicare provider is right for your CBO  in the Business Institute’s Becoming a Medicare Fee-For-Service Provider: What CBOs Need to Know
  •  Currently, most of the Medicare billing for CBOs is centered around self-management, health and wellness promotion programs, care transitions, and well as care management services. There are a number of Medicare Part B benefits that can be offered to obtain reimbursement for Chronic Disease Self-Management Education (CDSME) programs by billing Medicare directly. However, it is important to note that for the Chronic Care Management (CCM) and Complex Chronic Care Management (Complex CCM) services described below, a CBO cannot bill Medicare directly. They must partner with a physician or an eligible non-physician practitionerwho can submit bills to Medicare for reimbursement.

Below are the benefits most commonly furnished by CBOs, along with their corresponding billing codes. (Note: CPT codes stand for Current Procedural Terminology codes. CPT codes are a set of medical billing codes that are developed and owned by the American Medical Association.) 

Diabetes Self-Management Training (DSMT)

Medical Nutrition Therapy (MNT)

Health Behavior and Assessment Intervention (HBAI)

Chronic Care Management (CCM)

Complex Chronic Care Management (Complex CCM)