Abstract
Context: Although Medicare and several state Medicaid programs are beginning to cover the cost of delivering the National Diabetes Prevention Program (National DPP), little is known about the logistical challenges to establishing reimbursement options for these services.
Objective: To describe Los Angeles' experience working with payers to identify and establish reimbursement pathways for National DPP providers.
Design: A case study was conducted to identify regional options for covering the costs of the National DPP.
Setting: Los Angeles.
Participants: A managed care organization along with selected National DPP providers (those that provide in-person and/or online services) participated in this regional pilot project.
Intervention: The Los Angeles County Department of Public Health explored and prototyped reimbursement options for the National DPP, using input from and participation by target health plans (payers) and program providers.
Main Outcome Measure: The establishment of a regional reimbursement approach for the National DPP.
Results: Pilot project participants weighed the pros and cons of billing (Medicare/Medicaid)/reimbursing for program services directly, ultimately choosing to go with a third-party integrator that worked with payers to handle the administrative process of reimbursing program providers for their services. The integrator negotiated and obtained reimbursements on the behalf of the National DPP providers.
Conclusions: Lessons from this case study suggest an emerging need to build further capacity among National DPP providers, as they are often community-based organizations that are not equipped to bill Medicare/Medicaid directly for services. A third-party integrator represents a viable approach for addressing this logistical issue.