Why is it that enteral nutrition products may not be eligible for reimbursement during an acute care admission by some facilities? Implications for Practice: EN products may or may not be eligible for reimbursement during an acute care admission since many facilities consider EN a “food,” including it as part of the daily charge. For example, under Medicare Part A guidelines, EN therapy is typically considered part of a diagnosis-related group (DRG), therefore, and is not separately reimbursable. Among patients expected to receive home EN, the formula and associated supplies are reimbursed through a government program such as Medicaid or Medicare, commercial health insurance, or private pay. For Medicare beneficiaries, coverage is available through the Part B prosthetic device benefit for which patients must have documentation in their medical record indicating they meet the following criteria: there must be permanent functional impairment of the GI tract (ie, permanent nonfunction or dis- ease of the structures that normally permit food to reach or be absorbed from the small bowel), and EN is deemed to be beneficial and necessary for the beneficiary (patient), as well as deemed necessary to maintain weight and strength commensurate with health status.96 To receive reimbursement for “specialty” EN formulas, proper documentation and justification must be submitted to the Centers for Medicare & Medicaid Services (CMS). Many insurers follow reimbursement guidelines similar to those used by CMS; however, it is always recommended that health insurance providers are contacted to determine coverage for EN therapy prior to initiation. EN products can be costly and, in some cases, may not be feasible for patients to administer at home due to out-of-pocket costs.
Review the “Implications for Practice” section (Cont...)
Why is it that enteral nutrition products may not be eligible for reimbursement during an acute care admission by some facilities?
Implications for Practice:
EN products may or may not be eligible for reimbursement during an acute care admission since many facilities consider EN a “food,” including it as part of the daily charge. For example, under Medicare Part A guidelines, EN therapy is typically considered part of a diagnosis-related group (DRG), therefore, and is not separately reimbursable. Among patients expected to receive home EN, the formula and associated supplies are reimbursed through a government program such as Medicaid or Medicare, commercial health insurance, or private
pay. For Medicare beneficiaries, coverage is available through the Part B prosthetic device benefit for which patients must have documentation in their medical record indicating they meet the following criteria: there must be permanent functional impairment of the GI tract (ie, permanent nonfunction or dis-
ease of the structures that normally permit food to reach or be absorbed from the small bowel), and EN is deemed to be beneficial and necessary for the beneficiary (patient), as well as deemed necessary to maintain weight and strength commensurate with health status.96 To receive reimbursement for “specialty” EN formulas, proper documentation and justification must be submitted to the Centers for Medicare & Medicaid Services (CMS). Many insurers follow reimbursement guidelines similar to those used by CMS; however, it is always recommended that health insurance providers are contacted to determine coverage for EN therapy prior to initiation. EN products can be costly and, in some cases, may not be feasible for patients to administer at home due to out-of-pocket costs.
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