Reimbursement Issues in Diabetes

Third-party reimbursement for outpatient education services and for new health care technologies in diabetes is an issue of concern to educators, administrators, and others in the diabetes health care system. Reimbursement for outpatient education has been obtained from 11 Blue Cross/Blue Shield plans in nine states, six commercial insurance companies in four states, Medicare in five states, and Medicaid in one state. Despite these successes, third-party payers still must be approached on an individual basis. We review approaches taken by different states and diabetes control programs and make recommendations on how to request third-party reimbursement for outpatient education services. Third-party reimbursement of diabetes-related technologies/services and equipment is found to be dependent on the type of coverage the individual has, the state in which he or she is located, and the item or procedure covered. Many third-party payers do not have stated policies on reimbursement of a particular piece of equipment such as the insulin pump, or they do not have consistent, well-communicated standards for determining coverage.