Division of Chronic Disease and Injury Prevention, Los Angeles Department of Public Health, Los Angeles, California (Drs Mosst and Kuo and Mss DeFosset and Sivashanmugam); Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California (Dr Kuo); Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California (Dr Kuo); and Population Health Program, UCLA Clinical and Translational Science Institute, Los Angeles, California (Dr Kuo).
J Public Health Manag Pract. 2021;27(3):E119-E125. doi: 10.1097/PHH.0000000000001136.
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.
To describe Los Angeles' experience working with payers to identify and establish reimbursement pathways for National DPP providers.
A case study was conducted to identify regional options for covering the costs of the National DPP.
Los Angeles.
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.
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.
The establishment of a regional reimbursement approach for the National DPP.
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.
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.
尽管医疗保险和一些州的医疗补助计划开始承担提供国家糖尿病预防计划（National DPP）的费用，但对于为这些服务建立报销选择的后勤挑战知之甚少。
描述洛杉矶与支付方合作，为 National DPP 提供者确定和建立报销途径的经验。
进行了一项案例研究，以确定覆盖 National DPP 成本的区域选择。
洛杉矶。
一家管理式医疗组织以及选定的 National DPP 提供者（提供面对面和/或在线服务的提供者）参与了这个区域试点项目。
洛杉矶县公共卫生部探索并为 National DPP 制定了报销选择方案，利用目标健康计划（支付方）和计划提供者的投入和参与。
National DPP 的区域报销方法的建立。
试点项目参与者权衡了直接为计划服务计费（医疗保险/医疗补助）/报销的利弊，最终选择了与第三方整合商合作，该整合商与支付方合作处理报销计划提供者服务的行政流程。整合商代表 National DPP 提供者进行谈判并获得报销。
从这个案例研究中得出的经验表明，National DPP 提供者需要进一步建立能力，因为他们通常是社区组织，没有直接向医疗保险/医疗补助计费服务的能力。第三方整合商代表了解决这一后勤问题的可行方法。
