The rise of virtual healthcare has been one of the biggest technology trends of the last decade, and telemedicine is poised to be a $20 billion dollar industry each year by 2020. Virtual nutrition, the offering of virtual services by nutrition professionals, is a rapidly increasing sector within this overall growing market. Health and wellness is a natural extension for virtual care, because:

• Most counseling and coaching services can be completed virtually, with no physical contact
• Ongoing interaction, rather than just one-on-one sessions, is critical for care outcomes
• Health and wellness providers can directly incorporate other aspects of virtual care into their offering: food logging, messaging, document sharing, group webinars, etc.

The benefits of offering virtual nutrition services extend to both providers and clients. Nutrition professionals are able to reach more clients, have more frequent check-ins, provide ongoing and real-time support, and bolster client accountability. This higher level of care and support motivates clients to make the consistent changes requires to achieve health goals.

So, how should providers think about implementation and pricing of virtual health and wellness services? In this article, we’ll review:

• Legal considerations & requirements for telehealth services in your state(s)
• How to incorporate telehealth as part of a broader virtual care strategy
• Best practices in setting rates for telehealth sessions
• Reimbursement strategies with insurance-based clients

Navigating Legal Considerations with Telehealth Nutrition

Master the legal considerations in your state, and the state of your client.

Telehealth in the United States is affected by laws and regulations at both a federal and state level. There is no uniform approach to telehealth reimbursement, regulation, and policy, and there are variances on a state, insurance, and provider-type basis.

If your licensure requires liability insurance, ensure that your insurance covers virtual services

Obtain informed consent from clients to counsel them virtually.

Kristi Coughlin, MS RDN/LD of For Dietitians, manages a completely virtual nutrition business. She emphasizes obtaining informed consent each from virtual clients at each and every session.

“Simply put, informed consent it is the communication between the provider and the client outlining the benefits and risks associated with participating in telehealth services to ensure the client is making an informed decision.” Kristi suggests that as a best practice, to always write a chart note post-session, even if your service is self-pay.

Incorporating Telehealth Nutrition into Your Services

Virtual nutrition care can consist of the following elements:

• One-on-one video chat meeting
• A group webinar / video meeting (note: make sure you have a privacy disclaimer if doing this)
• Food logging
• Secure messaging
• Document sharing & delivery
• Program content creation & delivery

Contrary to popular belief, virtual care solutions can (and should) be combined with any in-person services you may already offer. Telehealth nutrition services can serve as a natural way to evolve your offerings and extend your reach. Many medical clinics, as an example, are finding success partnering with dietitians to offer nutrition counseling, in person and virtually.

We see our providers structuring their business’s with any of the following:

• Completely self-pay, 100% virtual nutrition practice
• Completely self-pay, with a combination of in-person and virtual nutrition services
• Combination self-pay and insurance-based, 100% virtual nutrition practice
• Combination self-pay and insurance-based, with a combination of in-person and virtual nutrition services
• Completely insurance-based, with a combination of in-person and virtual nutrition services

Pricing Telehealth Nutrition Services

In this section, we run through a framework by which you can calculate prices for your services, and then apply this framework to common packages we see our providers offer.

There are of course, several complexifiers as you think through particular pricing for your business, and pricing is definitively an art, not a science.

Follow these 6 steps to establish a self-pay rate that will cover your expenses and keep you on track with your financial plan.

Step 1: Determine your business’s profit, revenue, and expense targets

• Set your goal profit each month: How much do you want your business to bring in?
• Evaluate your business expenses (rent, utilities, marketing, software platforms, conferences)
• Calculate the revenue you need to bring in each month to offset your expenses and achieve your profit

Note: You’ll likely want to model this out in an excel spreadsheet, or financial modeling tool.

You will be able to work backwards from these numbers, to hone in on a) whether your profit numbers are realistic, and b) what it would require for you to achieve your goals, on a daily, weekly, and monthly basis. You will also use your reasonable hourly rate, outlined below, to triangulate whether your targets are realistic.

Example:

Goal Profit: $5000/month

Expenses: $2000/month

• Rent + Utilities: $1500/month
• Marketing: $200/month
• Software Platforms: $200/month
• Conferences + Professional Meetings: $100/month

Step 2: Calculate your desired hourly rate

Based on your revenue target determined in Step 1, determine how many hours per week you are planning to devote to virtual care delivery.

Example:

Total time commitment = 14 hours/week

Step 3: Determine how many clients it will take to achieve this

Example:

Hours/week set aside for private practice = 14 hours/week (56 hours/month)

Goal Monthly active clients (MACs) =  15 MACs

Monthly Expenses = $2000/month

Goal Revenue = $5000/month

Based on these numbers, your hourly rate is the total revenue you’d like to achieve, divided by the number of hours you will work.

Example:  

$5000 total revenue divided by 56 hours/month  ~ $90/hour

Our beliefs:

• It’s incredibly important for business owners to have an ongoing, real-time snapshot of their business numbers. We see many providers shy away from this sensitive, and often difficult topic, but keeping a transparent picture of your business is vital for your long-term success.
• You should approach pricing the same for in-person and virtual services. Yes, you may have a lower overhead cost, in terms of office space needs, but your time and expertise, remains the same. You’re still You’re still providing the same level of care, and your time reflects that.

Step 4. Detail out what your package would include and the amount of time that realistically these services will provide

Many dietitians shy away from charging for the time they spend between sessions, supporting clients. The time spent messaging your client, checking in, answering questions, reviewing food diaries quickly adds up. If not accounted for in your pricing, you’re effective giving a lot of your time away for free. Knowing your worth and valuing your time, will ensure that clients also value your time. So when creating and pricing your self-pay rates, be sure to think through all of the time you actually spend working with each client.

Example:

1 Month “Total Accountability” Package:

• 1 Initial Session: 60 minutes
• 2 Follow-Up sessions: 30 minutes x 2
• Food diary review weekly: 15 minutes x 4
• Questions + Message support weekly: 15 minutes x 4

Total time actually spent = 4 hours/client each month

Step 5. Multiply your total time spent by your hourly rate

To calculate the rate for your virtual nutrition counseling package, you’ll want to multiple the total time that you’ll spend with each client, by your hourly rate. This will ensure that you’re including the between session support within your pricing.

Example:

4 hours (spent monthly per client) x $90/hour = $360 for 1 Month “Total Accountability” Package

Step 6. Markup your rate to include what you’ll have to pay for taxes

Once you have your hourly rate, and your package price, you’ll want to make adjustments for taxes, credit card processing fees and any other important savings you need to set money aside for (like retirement or healthcare). Self-employment tax is a tax consisting of Social Security and Medicare taxes primarily for individuals who work for themselves. It is similar to the Social Security and Medicare taxes withheld from the pay of most wage earners. Currently, the self-employment tax is 15.3%. Read more on calculating self-employment tax rates from the IRS website.

Example:

$360 for 1 Month “Total Accountability” Package + 15.3% tax markup + $2 credit card processing fee

Final Package Rate = $417.08

Obtaining Payment from Virtual Clients

We suggest that for any client (self-pay or insurance-based), you obtain a credit card on file as part of your intake paperwork/process. This eliminates the need to send clients a bill for services, that may remain unpaid or have to go through a collections process. It also can be used to reinforce your cancellation policy, if you have one in place. Use a secure platform for storing billing information to help keep your clients’ information safe.

You can charge your client for services after your session concludes. If you offer a package, you may want to provide automatic payments monthly, which can be setup through the Healthie billing platform.

If you are currently in-network with insurance companies, with most of your clients come in from these channels, then starting to offer virtual nutrition services as a way to support your in-person clients can be a value add-on. The challenge in this scenario is navigating the unclear terrain of reimbursement for telehealth nutrition services through insurance claims

Navigating Legal Considerations with Virtual Nutrition Counseling

Due to the variance in state telehealth laws, there is also inconsistency in how insurance companies define and reimburse for telehealth services. Traditionally, telehealth has been used by medical doctors, dermatologists and psychiatrists. Virtual nutrition care is a relatively newer service being considered and approved by insurance providers for coverage, and reimbursement overall depends on many variants.

Insurance Reimbursement for Telehealth Services

1. Call the insurance provider of your client (and preferably the client) in advance to verbally confirm telehealth coverage
2. Clarify how the insurance carrier classifies telehealth (is it video-chat only, or does it also include phone calls?)
3. Use a HIPAA-compliant telehealth platform (phone, Skype and Facetime are not considered HIPAA compliant) and double-check with the insurance carrier if they have any specifications on telehealth platforms used. In some instances, insurance companies may require a specific telehealth platform be used
4. Make sure that your professional liability insurance covers for telehealth services.

If telehealth nutrition services are not covered for your client, you can still offer them virtual support at a self-pay rate. Consider offering a phone or video call as an alternative to in-person sessions, at a self-pay rate.

Another way to incorporate more virtual services into your insurance-based practice is by offering virtual support for a monthly subscription rate. Depending on your client needs, offering a monthly self-pay rate:

• Between session accountability subscription: including food journal reviews and ongoing messaging/support
• Group chat support: moderate a group chat on a HIPAA-compliant platform for participants to share ideas, challenges, recipes and more.
• Virtual support groups or challenge: proving group support can be a valuable way to further support your in-person clients. However, finding a location, coordinate a time and paying for the expenses can be a deterrent. Offering virtual group support on a HIPAA-compliant platform can be a great way to save on costs and have better attendance. For liability purposes, have participants sign-off on a waiver form when they will be sharing their health information to others in a group setting.
• Online wellness program: bundle nutrition resources into one comprehensive program and schedule out content to automatically distribute to enrolled participants. Offer your wellness program as an add-on service for existing clients, or use it to market to new clients.

Submitting CMS 1500 Claims for Telehealth Services

If you’ve confirmed that your insurance-based client is covered for virtual nutrition services, you’ll need to make an adjustment in your CMS 1500 claim. Namely, the place of service (POS) will change to 02 for telehealth nutrition session. The telehealth POS code is a relatively new (introduced in 2018), change and replaced previously used modifiers for telehealth (ie GT modifier). You can read more on the change here.

Within the Healthie billing platform, you can quickly generate CMS 1500 claims post-session, which autofill based on your information. Simply update the POS to adjust your claim for a telehealth session.

When to Provide a Superbill

If your client self-paid for your services, they may still be able to submit the receipt to their insurance company for partial reimbursement, or credit towards their flex spending or health savings accounts. In this event, you should provide them with a Superbill. This detailed receipt of services provides all of the information the insurance company needs to process a healthcare claim.

As best practices in her self-pay virtual practice, Kristi discusses with her clients upfront the purpose of superbills.  “As a self-pay practice, I provide a Superbill to clients who have requested it. When I first discuss with my client, package types and payment, I describe the purpose of a Superbill.” From there, she provides a superbill at the clients’ request if they are interested.

Obtaining Payments for Insurance-Based Clients

• Put in place a financial agreement policy, that clearly indicates your client is responsible for payment if insurance does not approve their claim (and for any portion of the payment not covered by insurance). You can also include the pricing for any additional self-pay services (like monthly support, group sessions, programs) on your financial agreement form, or create a separate self-pay policy form.
• Collect copays at the time of service (unless with high-deductible plans or for plans that don’t clearly indicate what the copay amount is).
• Have a credit card on file so that in the event a claim is not processed, you have a way to charge a client for their remaining balance
• Use a secure platform for storing billing information

As you go through the motions of establishing virtual nutrition counseling services in your practice, you may want to make adjustments as you go. The telehealth landscape is constantly evolving as laws and regulations change on both the federal and state level, as well as changes to how insurance companies define and cover for telehealth services. It’s an ongoing process to ensure that you are compliant with telehealth regulations, but the value of providing virtual services is worth the effort.