A Tale of Two Entities

With Medicare now offering hundreds of dollars per participant in reimbursement for diabetes preventative services, many organizations are interested in becoming part of the solution to this national health crisis. We don’t want to scare the Dickens out of you, but if you’re considering offering the Medicare Diabetes Prevention Program (MDPP) at your facility, there are several steps you’ll need to take.

Let’s take a look at this innovative program to see what’s required of your organization and team members. We’ll try to demystify the difference in rules for the two government agencies running the program, and we’ll give you a quick list of the steps you need to take.

One Program, Two Sets of Rules

Dealing with two government entities on a single program, each with their specific needs, can lead to countless hours pouring over rules and regulations that can be confusing at first. As you come to understand the reporting and performance requirements it may feel like they are convoluted, contradictory or just plain crazy. But, when you understand how these two groups are collaborating, it’s easier to understand the motives behind this amazing opportunity.

Centers for Disease Control and Prevention (CDC)

CDC oversees and assures the quality of the National DPP:

  • Develops and maintains the Diabetes Prevention Recognition Program (DPRP) Standards
  • Evaluates organizations for achievement of recognition status
  • Maintains a registry of recognized organizations
  • Provides resources to support organizations in achieving and maintaining CDC recognition
  • Reviews and approves alternate curricula
  • Updates National DPP curriculum

Centers for Medicare and Medicaid Services (CMS)

CMS is implementing and evaluating the MDPP expanded model:

  • Defines the Medicare covered MDPP services.
  • Supports supplier enrollment and submission of claims
  • Processes enrollment applications for qualifying organizations
  • Provides resources to verify certain elements of beneficiary eligibility for MDPP
  • Processes claims submitted by MDPP suppliers for payment
  • Monitors suppliers’ compliance with Medicare requirements and MDPP supplier standard

It’s important to understand - you can run CDC’s DPP without running CMS’s MDPP. It just means that you will not get reimbursed (but it also means you don’t need to meet CMS requirements!). But for the rest of this article, we’ll assume you are interested in getting reimbursed for the services. So we will discuss MDPP and all of its glory.

Start with the CDC

Complying with CDC’s regulations is important because CDC Full Recognition Status must be maintained in order for your organization to be an official supplier of the Medicare Diabetes Prevention Program (MDPP).

*Did you know? Since issuing the DPP Final Rule in November 2017, it’s been updated twice!

Here’s a quick list of steps to meet CDC rules:

1. Do Your Research. Understand the basics of the program, such as the CDC-provided educational materials, phases (Core, Core Maintenance, etc), the routines (education delivery, weight checks, physical activity), and the cohorts (a group of participants). Find yourself a HIPAA compliant tool to help keep track of the data, such as Welld Health (welldhealth.com/diabetes-prevention).

2. Apply. The process to apply for recognition is pretty straightforward, and there are many easy-to-follow guides provided by the CDC to help you get your program on the road to recognition. You’ll want to make sure your organization has the capacity to deliver the DPP. It is best to wait until your organization is within a month or so of starting a cohort to seek the Organization Number from the CDC. This is because your effective date is the date that governs your reporting schedule - to CDC.

3. Train the Staff. Like any program offered by your facility, DPP needs to have a champion to succeed. This person should be a DPP Master Trainer who can train your Lifestyle Coaches and can also serve as your program coordinator. CDC has resources to get your designated staff trained up, but plan to work on more than one front at a time. While promoting the program to get a cohort together, train the staff and organize your program delivery operations. There are a lot of moving parts in the DPP, from managing staff permissions to setting up new cohorts, assigning coaches and keeps tabs on those ever-important KPI’s.

4. Characterize the Participants. CDC uses the demographic data you will for each participant applicant to assess the efficacy, reach and impact of the program in our communities. In order to participate, applicants have be eligible according to the CDC rules:

  • Be enrolled in Medicare Part B
  • Over 18
  • Overweight with BMI ≥25; ≥23 if Asian
  • Have had a blood test in the past year in the prediabetes range OR
  • Have had a previous diagnosis of gestational diabetes mellitus (GDM)
  • Have had no previous diagnosis of diabetes, with the exception of GDM, or end-stage renal disease
  • Their race, ethnicity, insurance information, and risk score (if they completed the optional risk test) will also be recorded during an eligibility onboarding session.

5. Achieve CDC Recognition. You’ll begin to deliver the MDPP with under a Pending Status. This is your proving ground and opportunity. You must submit performance data to the CDC every six months from your effective date. Once you have a cohort that has gone through the Core and Core Maintenance phases of the program, your organization will be reviewed to determine if you’ve earned Full Recognition status. The official CDC-approved curriculum to meets the duration, intensity, and reporting requirements is described in the DPRP Standards, but is our quick take on them:

In order to obtain recognition you will need to have (this is where it gets fun):

  • A minimum of 5 participants who have completed at least 3 sessions during the Core services period and who have been in the program for at least 9 months. Additionally, your qualified participants must show an average 5% weight loss.
  • A minimum of five participants that have:
    1. Completed at least 3 sessions during the Core services period
    2. AND been in the program for at least 9 months.
    3. AND show an average 5% weight loss.
    4. AND have 80% of sessions attended with a weight measurement
    5. AND have 60% of sessions attended with physical activity recorded

It’s pretty straightforward to get your pending status, but making sure your program is on-track to receive full-recognition is something you need to see over the course of the first full year of program delivery. It’s not good enough to see your metrics once before it’s too late to do anything about them. You need to obtain full-recognition from the CDC in order to be able to remain enrolled as a Medicare Supplier once you complete the first year.

6. Conduct Cohorts, Events & Sessions. Schedule events. Convene meetings. Measuring weight. Record attendance. Document physical activity. Do these at every session for every participant for two-years, and you'll have what it takes to obtain and retain your recognition status. Conducting and managing these events is at the heart of MDPP. You will need to allow for in-person and virtual make-up sessions (which have their own rules). The enthusiasm of your team to fuel this program and to help your participants reach the program goals will set your organization apart. But you’ll need a tool to help. Do not try to manage all of this in Excel or in your club software, it gets messy and complicated fast.

Now for the CMS Requirements

If you’re confident in your ability to meet CDC’s needs, it’s time to evaluate your ability to meet CMS requirements.

1. Get a National Provider Number. Pretty quickly, you’ll want to obtain your National Provider Number for both the organization and for each of the coaches on your staff.

2. Enroll as a Medicare Supplier. Once your organization has completed the CDC application and obtained an organization number, effective date, and submitted data on at least one full 12-month cohort, submit your application to be a Medicare Services Supplier. Depending on your organization’s ownership structure the Medicare Administrative Contractor (MAC) may request fingerprinting and background checks.

3. Deliver an outcomes-based program. The goal is simple for the MDPP: lose 5% of body weight,verified by two weigh-ins at least 12 months apart. Sounds easy enough, but this covers only the participant requirements for the MDPP. The requirements to continue to deliver MDPP services are directly tied to maintaining your CDC recognition (see above).

4. Maintain CMS Provider Recognition. In addition to the CDC submission described above, you will electronically deliver a separate crosswalk report to CMS every six months during a designated submission window. The purpose of the crosswalk file is to:

  1. Verify the organization CDC status
  2. Verify each participant’s session attendance, education received and weight loss.

5. Produce Reimbursement Requests. The third type of file you’ll need to produce is a billing file, full of data about exactly who and why you are expecting reimbursement. You have a choice: submit directly to CMS, or use a third party billing service. For those of you in the Physical Therapy world, you’ll like be able to reuse your current billing strategy. For those of you who are just getting into the practice of medical reimbursement, Welld Health can introduce you to billing providers.

6. Earn More Money. While the participant requirements to remain eligible for the benefit may be low, it’s to your advantage to entice and engage them to do more. There are many points along the program where a participant will pass a threshold, letting you submit another reimbursement request. If you want to realize the full $670 reimbursement potential, get your participants into your facility on a weekly basis. Collect weight and active minutes in a secure and safe manner. Find a tool to help. Welld Health can manage your staff, cohorts, track sessions, progress toward goals and will generate billing files for you.

We’re here to help.

While there is a lot of information about the MDPP on the web, sometimes it helps to have a partner to help. Hopefully this list has given you sense of the depth of requirements it takes to run the Medicare Diabetes Prevention Program. If you’re thinking about adding MDPP to your program offerings or are ready to get started, feel free to read more at welldhealth.com, setup a demo or reach out to info@welldhealth.com.