Medical Homes are the Best Source of Reimbursement for Optometrists

By Mark A. Ridenour

This could very well be a headline in the future given the direction of changes in the healthcare industry today.  Many Primary Care Physician (PCP) practices have converted to the Patient-Centered Medical Home (PCMH) practice model.  There are now more the 7000 accredited Medical Home practices nationwide with 535 in Ohio.  PCPs have embraced this model because it allows them more practice freedom, offers the opportunity for increased reimbursement, improves their patient’s outcomes, and increases their patient satisfaction; not necessarily in that order.  PCP practices must meet numerous criteria to be considered a Medical Home, including 24-hour remote patient access, next day appointments, coordination of patient’s care with other providers, and team-based provider care with specific expertise around nutrition and behavioral change.  Physicians who have successful migrated to this model report greater job satisfaction themselves, because they are put into more of a CEO role, where the more complicated cases and decisions come to them and more routine care is seen by mid-level staff.  Patient response to this transformation has been mixed, but many insurers are now incentivizing their members to use Medical Homes via reduced co-pays and benefit design.

Payers (insurance companies, employers, and government) have discovered PCPs operating as Medical Homes lowers their costs.  Reducing emergency room admission rates and eliminating duplication of diagnostic tests are examples of quick payoffs.  Typically, they will pay these practices extra for care coordination and case management and/or pay bonuses for improved patient population health outcomes.  Many payers have shifted their risk to the Medical Home; i.e., they have given the Medical Home a percentage of the employer/employee premium to manage the patient.  The Medical Home, in turn, must manage the expenses of the patients, leading them to become more discerning about referrals.  Insurers will supplement this because a parallel objective they have is to reduce the most expensive care they pay for – hospital and specialty care.  This is one of these reasons the OOA continues to stress the importance of your relationship to your PCP referral sources.  Medical Homes will likely establish criteria for referrals to Optometrists.  Which practices supply me with the best and timely information about my patients?  Do I consistently receive exam results on my diabetic patients?  Are they encouraging them to maintain healthy behaviors?  Are they accessible for eye care emergencies?

This movement in the provider payment landscape is part of the reason the OOA continues to promote the Optometrist as the primary eye care provider.  Along with dental and behavioral care, optometric services are generally perceived as essential preventive care.  As long as fee-for-service reimbursement dominates, it is beneficial to be aligned as a primary care provider.  Payers are favoring reimbursement codes for these services over specialty care codes.  Plus, any alternative payment models will be based on the premise of investing in preventive care to avoid greater catastrophic costs.

So you may not be getting reimbursement checks from PCPs yet,….. but it may not be far down the road.  Now is the time to recognize this shift and solidify our relationships via active interactions and demonstrations of value.  Are PCPs likely to value Optometrists more than the insurance companies?  Now is the time to start influencing the answer.

For more information on the Medical Home model and specific information on those in Ohio go to the Ohio Department of Health website at http://www.odh.ohio.gov/pcmh.

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Blogs or Books? Guesses or Guidelines? It’s time to get serious about good medical records.

By: Charles B. Brownlow, OD  (drbrownlow@pmi-eyes.com)

Several years ago, I found myself jumping from one eye care chat room to another, trying in vain to correct bad information about patient care and record keeping that kept popping up there.  It seemed that my colleagues in eye care would rather ‘take a poll’ of other ODs and staff (who didn’t know the answer either) rather than go to the only true authorities.  After getting totally frustrated in that ‘Whack a Mole’ environment, I respectfully and quietly withdrew from the milieu, and I haven’t missed it one bit.

Over a decade ago, during the ramp up to HIPAA, the rules changed essentially clarifying that Current Procedural Terminology (©American Medical Association), ICD-9, and the Documentation Guidelines for the Evaluation and Management Services (99000 visit codes) were the sole acceptable references for codes and definitions for the vast majority of health care services.  That thought clarifies nearly everything in health care…All a health care provider needs to do to learn about the logic of health care delivery, good medical record keeping, and accurate choices of procedure, visit and diagnosis codes is purchase the current year’s CPT and a fresh ICD manual and download the 1997 Documentation Guidelines from CMS.gov.

Based on the questions that I get every day from ODs and staff from around the country, it’s pretty clear that a majority of those offices do not have those key references available in-house, or they are not current, or they just don’t refer to them when question arise.  That’s pretty sad, I think.  CPT is available through our AOA.org/marketplace at $100 a copy.  The Documentation Guidelines are a free download (.pdf or Word) at cms.gov.  ICD-9 and ICD-10 are available as complete manuals for around $100.  So, for between $200 and $250 per year, key staff and doctors could become ‘experts’ on the chat room scene real quickly.

I’ll provide a couple of examples to support my point.  One of the long-raging arguments among eye doctors; at least twenty years; has been whether the CPT definition of the comprehensive ophthalmological service (92004/92014) includes a dilated fundus examination as a requirement.  The definition has not changed since 1992 and it has never included that requirement!  The CPT definition clearly lists “…examination with cycloplegia or mydriasis” among the tests that the service “…often includes, as indicated”.  “Often includes” does not equate to “includes” or “is required.”

I think the confusion may come from the requirements for the ‘comprehensive physical examination’ for the evaluation and management services (99000 codes), but it was made very clear back when the 99000 codes were introduced nearly twenty years ago that the CPT definitions are unique and distinct for each set of visit codes and that there are no crosswalks or comparisons between the two.  In short, “external and ophthalmoscopic examinations” are required elements for 92004/92014…Dilation is not.

One of the national speakers in the medical record area continued to state that dilation was a requirement. Every year I would hear that, refer to my then current CPT book for confirmation that I was still right, and shoot off an email to suggest that the speaker ‘change his tune’.  Months later, I’d hear that the message had not changed.  Finally, early one year, with the ink barely dry on my current copy of CPT, I heard again that dilation was required.  Instead of emailing again, I picked up the phone and called. “Hey, how are you doing?  Keeping out of trouble?  Family doing fine”, etc.  After about 30 seconds of small talk I dropped my challenge.  “It’s right there in the definition”, the speaker replied. Then it hit me and I responded, “Which CPT book says that?”  “Why, the (Brand X) CPT, of course”, he parried.  FLASH!  The lights snapped on.  He wasn’t using the only official CPT book, the AMA CPT, he was using a cheap imitation, the book that continues to confuse the issues, the (Brand X) CPT!

As with so many things, we must accept no substitutes.  If I’m ever in court, I’ll want an attorney who knows the laws and, when pressed, is able to refer to the current, official statutes that pertain to the case.  I’m not going to be very comfortable if the attorney attempts to reassure me by saying that she got the information off a blog or chat room, or that he called a couple of friends or read it in a novel.  The same is true with medical records.  The care you provide had better be consistent with accepted modes of practice; the standards of care; and the medical records you keep must demonstrate clear connections between the needs of the patient and what was done, and your choices of procedure and visit codes must have been chosen by comparing the content of the chart and the definitions in AMA CPT and the current ICD listings.

Relying upon trusted resources and references can help us avoid hassles and sometimes disasters.  I know you’ve been putting this off for a long time.  Just do it today.  Get your 2015 copies of CPT and ICD-9 (and ICD-10).  Read the introductions at the front of the CPT book and the front of the 1997 Documentation Guidelines.  And then refer to those key references when questions pop up.  You’ll sleep better…You’ll find yourself chuckling quietly when you ‘listen’ in on a discussion in a chat room or read somebody’s blog…Then, without typing a response, you’ll go to the references, double check your understanding of the question, and live happily ever after.  You’re welcome.

State Innovation Model – 75 Million Reasons to Pay Attention

By Mark Ridenour

In December, the Center for Medicare and Medicaid Innovation (CMMI) awarded a $75 Million four year grant to the Ohio via its State Innovation Model (SIM) awards to implement a payment reform model which will broadly move reimbursement models to recognize outcomes over volumes.  Providers will get increased reimbursement for providing more efficient care while maintaining or improving quality.  Ohio budget projections suggest another $125 Million in state funds could be added over the life of this project.  The stated SIM goal is to have 80-90 percent of Ohio’s population in some value-based payment model within five years.

The Ohio Office of Health Transformation (OHT) led by Director Greg Moody will manage this project.  There are two primary vehicles designed to work together to implement this change: 1) Episodes of Care and 2) Medical Homes.  (see chart below) The state will require each of the managed Medicaid insurers (CareSource, Buckeye, Molina, Paramount, and United) to participate along with the four largest commercial insurers (Anthem, Aetna, Medical Mutual and United).  In 2015, these payers will share data with providers on selected Episodes and begin to change payments in 2016.  The initial Episodes are Perinatal, Asthma acute exacerbation, COPD exacerbation, Percutaneous Coronary Intervention (PCI), and total joint replacement.

Capture

There are now over 500 accredited Medical Homes in Ohio.  This project will initially work with the 75 Medical Homes in the Cincinnati-Dayton region already engaged with the Comprehensive Primary Care initiative (CPCi), additionally funded by CMS.  This will progress by region in Ohio most likely taking advantage of the significant work already accomplished by the health collaboratives, Better Health Greater Cleveland and the Healthcare Collaborative of Greater Columbus.  The OOA has been a supportive participant over the past few years, although optometry has yet to demonstrate an impactful relationship.

Capture 1This chart represents the variability in total costs across an episode and how the OHT envisions introducing risk and gain sharing.  While the initial episodes chosen do not directly involve optometric care, we are confident that as the list grows to the expected 50 episodes they will likely include diabetes, glaucoma and/or cataract care.  The OOA has been engaged with the OHT so will be part of the stakeholder groups helping to shape this effort.

What can you do now to prepare for the changes brought about by this significant investment in the State Innovation Model (SIM)?  1) affiliate with Medical Homes and 2) maintain an Electronic Health Record (EHR) which meets Meaningful Use standards.

The best position for optometry as the primary eye care provider is to solidify our standing as part of primary care team via alignment with Medical Homes.  You should survey your primary care referral sources to see if they are an accredited Medical Home or are in process.  Maps and lists of accredited practices are available on the Ohio Department of Health website.  In addition, even though the promise of electronic interconnectedness has yet to be realized, participating in risk-sharing, outcomes-based reimbursement vehicles will be largely dependent on providers having EHRs with the ability to send and receive data.

Medicare Update for 2015

Medicare Update for 2015

Dr Brownlow

10 and 90 day global periods will be eliminated for minor surgical procedures in 2017 and for major surgical procedures in 2018.  Current 0, 10, and 90 day post op periods are still in effect for 2015!  Lots of ODs and staff have been asking me about the potential impact of all global periods going to 0 days.  Actually, I think it will be an advantage, as doctors providing post op care will no longer be limited by the meager CMS payments for post op periods, and will be submit claims for whatever visits and procedures are necessary during the post op period, just as they are during any other time they are caring for the patient.  Another interesting thing I’ve noticed about this issue…I’ve been getting more questions regarding these changes; though they won’t go into effect for two or three years; than I get on issues that should be of concern to doctors and staff currently and/or should have been of concern to docs and staff for years…Go figure!

Medicare Fee Schedule

The 2015 Medicare Fee Schedule has been published and it does include some changes, resulting in small net increases across the board for services ODs provide most commonly. Medicare’s fees are calculated based on relative values assigned for each service and the Conversion Factor, set by Congress each year.  The formula for calculating the fee for each services is Relative Value x Conversion Factor = Fee.  The conversion factor will be slightly lower at the beginning of 2015, though some of the relative values have increased, so the net impact will be very small.  However, a very large decrease in the conversion factor is slated to go into effect April 1, 2015, unless Congress acts prior to that date.  For those of you who have watched this strange scenario play out in previous years, this is no surprise.  My prediction?  Congress will act in the 11th hour to avoid the big cuts and leave the fee schedule pretty much as it is in 2014.

Act Now to Avoid PQRS Penalties in the Future

AOA has been successful in convincing CMS that small group practices (1-9 doctors) should not be penalized for PQRS issues, but should be eligible for the PQRS bonus payments.  2017 PQRS bonuses will be earned by PQRS participation in 2015, so gear up now to be sure you qualify.  You can continue to report PQRS measures on your Medicare claims, although AOA will be providing members with an easier way to accomplish that reporting, referred to as ‘registry reporting’, early in 2015.  Watch for more PQRS information from AOA in December.  If you decide to begin (or continue) to use the traditional method of reporting PQRS measures on each Medicare claim, you may do that as well.  There are lots of PQRS changes for 2015, so please refer to all of the information that has been created by the AOA Third Party Center. It’s all available to AOA members at aoa.org/pqrs.  The major change for this year is that you must now report nine measures 50% of the time the related diagnoses appear on a claim.  Prior to his year you could have qualified by reporting only three PQRS measures 50% of the time the related diagnoses appear on a claim.  My advice at this point is to wait for AOA’s ‘Registry’ for PQRS reporting, which will make the process much more workable.

Medicare’s Impact on Optometry

CMS estimates that ODs provided services and were reimbursed over $1 billion in 2014 and predicts the total payments will rise in again for ODs in 2015.

Pretty amazing! And clear testimony of the value of your membership in the state association and AOA.  Without the hard work of organized optometry during the past thirty years and currently, we would not have been prepared to provide medical care to anyone, and we certainly would not have been granted full parity in Medicare, nor would we be providing full scope eye care services and being reimbursed by Medicare and other medical insurers today!

Charles B. Brownlow, OD, OS, OU

How to Appeal a Decision by Your Health Plan Issuer

The Ohio Department of Insurance has released a graphic depicting Individual/Patient/Member appeal rights and process flow, including external review.  You may find this helpful to supply this to your patients when you are aware they are not in agreement with their health insurer.  It may also help complement and reinforce an appeal you as a provider have initiated.

Flow Chart

The Sunshine Act – What Optometrists Need to Know

Dr. Elizabeth MuckleyBy Elizabeth Muckley, OD – Overview: The Sunshine Act, also referred to as the “Open Payments” Initiative, requires certain manufacturers that produce drugs, medical supplies and devices to publicly report payments or “other transfers of value” they made to physicians (including optometrists) and teaching hospitals.  Certain Group Purchasing Organizations (GPOs) will also be required to report annually to CMS ownerships or investments held by physicians or their immediate family, in addition to, payments and other transfers of value from the GPO to a physician that holds an ownership or investment interest in the GPO.

Impact on ODs: The Sunshine Act will affect optometrists because manufacturers will be required to track and report payments and transfers of value made to optometrists.  Manufacturer reports will be submitted to the Centers for Medicare & Medicaid Services (CMS) and CMS will ultimately make these reports publically available. Patients who are treated by optometrists may review this data.  It is important to emphasize that the burden of compliance falls to manufacturers. ODs are not required to report any information to CMS. However, to ensure that manufacturer and GPO reports are accurate, ODs may want to register to access their data prior to public posting and keep a record of payments and transfers of value received from manufacturers and GPOs.

Open Payments encourages physicians and hospitals to participate by tracking their financial relationships with applicable manufacturers and applicable GPOs and by reviewing data reported about them to ensure the accuracy of the information.

Key Dates: Manufacturers and GPOs began collecting data on Aug. 1, 2013.  Manufacturers and GPOs must report data to CMS as of March 31, 2014, and public reporting is scheduled to begin September 30, 2014. ODs can register, view and dispute July 14 – August 27, 2014.

Do you want to review Open Payments data reported about you before it is available to the public? Get started now by registering in CMS’ Enterprise Portal.

For more information visit:

http://www.aoa.org/advocacy/health-care-reform/the-sunshine-act?sso=y

http://www.cms.gov/Regulations-and-Guidance/Legislation/National-Physician-Payment-Transparency-Program/index.html

To register visit:

http://www.cms.gov/Regulations-and-Guidance/Legislation/National-Physician-Payment-Transparency-Program/Program-Registration.html

or

http://www.cms.gov/Regulations-and-Guidance/Legislation/National-Physician-Payment-Transparency-Program/Physicians.html

An ‘Info-torial’

Dr BrownlowBy Charles B. Brownlow, OD – I’ve been involved in some very frustrating experiences lately. I thought I would share them with you so that you gain perspective on your own frustrations. I was asked by an old friend practicing in another state to help find a way that ODs can bill more than their usual fees for services provided to Medicare. My friend is concerned that his colleagues’ fees are so low that they are not being appropriately reimbursed when they report those fees to Medicare. In some cases, Medicare is reimbursing multiples of the usual fees his colleagues are charging.

As a consultant, couldn’t I come up with a way around this conundrum? Couldn’t I suggest that AOA do something about this issue? Couldn’t AOA come up with a legal argument to permit ODs to violate their agreement with Medicare and bill something other than their usual charges? (A reminder: By contract, Medicare agrees to pay the lesser of the provider’s usual charge or the Medicare Fee Schedule Amount, with the result referred to by Medicare as the “Allowed Charge”, paid 80 percent by Medicare and 20 percent by the patient, after the $147 annual Medicare deductible has been met.)

Face it, some health care providers have low fees because they feel that is all their services are worth. They verify that belief by charging their private pay, uninsured patients those fees. Other providers believe their services have higher value, and they demonstrate that belief by charging real patients; private pay/uninsured patients; exactly those fees. Why is this so hard for some to understand?

Vision plans or Medicare are not responsible for establishing your fees…you are. Insurers only determine what they are willing to pay for services and/or materials. They are not responsible for determining what you will accept for your services…you are. Contracts between you and Medicare or vision plans or other medical plans are legal documents between businesses. Decisions made by businesses in contracting must be made by those businesses. Outsiders cannot influence those decisions. AOA cannot persuade insurers to change their fees or their policies. Individual contracting doctors can, but apparently too often believe they cannot and so they don’t try.

Accepting or rejecting contracts for your services without knowing your cost of providing those services is bad business and it could result in fiscal suicide, yet I’m convinced many ODs do exactly that. In a very real sense, by signing a contract without knowing whether the contract will provide any net benefit to your practice, you are simply turning over a portion of the success or failure of your practice to the insurers. Do they care about your practice as much as you should? Do they care about your patients as much as you should? Do they care about your employees, your community, your family, your retirement as much as you should? Of course not. That’s up to you.

Keep it simple. To the best of your ability, know and follow the rules of record keeping and coding and the stipulations of insurance provider agreements. Pressure your accountant and other consultants to help you determine what your fees need to be to cover your costs and create your target net income. Read the contract with each insurer annually, before renewal, and make firm, confident, informed, businesslike decisions about which to renew and which to negotiate or cancel. When masses of individual health providers take these simple steps, one practice at a time, things will improve.

An Update on Accountable Care Organizations (ACO)

mark ridenour july 2014By Mark Ridenour, OOA Consultant – Medicare now contracts with more than 360 ACOs nationally, each covering at least 5,000 patients for three years with Shared Savings. Ten ACOs are in Ohio; here’s a link to Medicare’s website where you can search for those organizations serving Ohio: https://data.cms.gov/ACO/Medicare-Shared-Savings-Program-Accountable-Care-O/ay8x-m5k6

Medicare rules include that patients are informed they are using an ACO and do not have to use network providers. ACOs may create private contracts with employers or other payers with different rules.

The Ohio Optometric Association is not aware of ODs being excluded. OOA is aware of OD groups and eyecare administrators signing with ACOs. The Harkin Amendment is intended to minimize the exclusion of provider groups including ODs; if you are aware of limitations on your scope of practice, notify the Ohio Optometric Association.

For more information, you can download a copy of The Accountable Care Guide provided by the AOA at: http://www.rethinkeyecare.com/wp-content/pdf/ACO-The-Accountable-Care-Guide.pdf.

 

The Affordable Care Act and Optometry

OSU student Erica KellerBy Erica Keller, Ohio State University, AOSA Trustee-elect – Recently, Rick Cornett, Executive Director of the Ohio Optometric Association, came to speak at The Ohio State University College of Optometry about the Affordable Care Act (ACA)/Obamacare and how it will affect optometrists, both positively and negatively. More than 150 students came to listen, making it apparent that we have an interest in the future of our profession under the ACA. We want to know: What does this legislation mean for optometry’s future?

1. How will the increase in consumers with insurance benefit optometrists?
The increase in insured patients will allow more people to come to optometry offices and have coverage for services provided. Due to the legislative work of Sen. Tom Harkin (author of the Harkin amendment, which became part of the law), optometrists have been included in many health care plans and have not been discriminated against by major insurance providers who are looking to cut costs.*

2. The Harkin Law and Optometry
The Harkin Law provides patients easier accessibility to an optometrist of their choosing and prevents insurance carriers from keeping optometry services out of health care plans.* Unfortunately, this may not be the case forever. The introduction of the H.R. 2817 bill would undo the progress the Harkin Law has made in the advancements of gaining coverage under a health care plan and eliminating the need to have a stand-alone vision care plan.* Fortunately, optometry is a strong profession and the American Optometric Association is working hard to fight this newly introduced bill.

3. What can we do as students to ensure H.R. 2817 does not pass?
Donate to AOA-PAC through your school representative and, if you have the opportunity, go to Washington D.C. and lobby for optometry’s future. If this bill passes, it would allow insurance companies to implement plans that limit patient access to vision care by optometrists.

4. What is the future of pediatric vision care?
The ACA has implemented an essential health benefit (EHB) requirement that will include pediatric vision care as one of 10 essential benefits required in health care plans. This vision care benefit will be integrated into the plan as a whole and will allow children under 18 to have one comprehensive eye exam per year and material benefits.* Children who may have never had vision care insurance in the past will now be covered.

5. Medicaid Coverage Enhancements
Starting this year, Medicaid will extend its coverage to anyone with income under 133 percent of the federal poverty line.* This will allow citizens who are childless and without insurance to be covered when they would not have been eligible for government assistance previously.* It is up to each individual state whether they will accept this Medicaid expansion. The states that choose to participate will receive more money to manage the increase in Medicaid participants, but this does not mean that payments will increase for providers.* Contact your state association to find out what is being done and what you can do to help ensure fair payment to providers.

While the ACA has been a politically divisive issue, we must take measures to educate ourselves on its impact.
Students have a responsibility to ensure they are informed and proactive. Changes to health care in this nation are inevitable. We can choose to watch from the sidelines or make our message clear: we are part of the solution.

Erica Keller is a student at The Ohio State University School of Optometry and a trustee-elect for the American Optometry Student Association (AOSA). Her column appears in the Spring 2014 edition of Foresight, the AOSA magazine, and was reprinted with permission.

* “Top 5 ACA Changes for 2014: Are You Ready?” American Optometric Association, 8 Jan. 2014. Web. 02 Feb. 2014.
<http://www.aoa.org/news/health-care-reform/top-5-aca-changes-for-2014-are-you-ready&gt;.

Coordination of Benefits – Why Make the Effort?

Miller 968Jason R. Miller, OD, MBA, FAAO – Please note: The following column is based on my experience and not an official opinion of the OOA. Every optometrist must decide how to handle this issue.

Are you confused about how to bill your diabetic patients? Especially your diabetic patients who also have VSP? Many health care payers have sent notices to many eye care providers asking for the claim when their member is diabetic. It’s kind of a blessing and a curse when two different carriers are asking for the claim with these specific patients. For example, this letter recently arrived in my office from Medical Mutual:

MedMut Form

 

 

 

These letters are correct when determining who to send the claims to, but need some clarification when it comes to actually submitting the claims and the order in which they are processed. There can be some confusion, as most vision insurances will not accept Refraction Only claims.

Determining who gets the bill starts with the reason for the visit. The patient’s reason for the visit should determine who gets the bill. If it is a refractive complaint (Myopia, Presbyopia, etc.), the vision plan should receive the bill for the encounter. If is a medical complaint (Diabetes, Dry eyes, Allergic Conjunctivitis, etc.), the medical insurance should get the bill for the encounter. That reason for the visit can be either a patient complaint or an order from the doctor at their previous visit (for example: Order Procedure: Glaucoma Work-Up in three months). That order from their previous encounter becomes the reason for the visit when they come in for that testing.

Typical Scenario:

If the patient is diabetic, they may be in for new glasses or contact lenses and their annual diabetic exam as prescribed by their primary care physician or endocrinologist. One possibility is to provide their vision exam (submit to vision) and have them back for any diabetic testing (submit to medical). That is typically not very patient-centric, as we can usually provide this service at the same time and will save the patient a trip to our office. This article details steps to take in order to coordinate the patient’s visit between both their Medical and VSP when appropriate.

  1. To coordinate this claim to VSP, there must be a refraction done on the same date as well.
  2. The exam can be either a 99xxx or 92xxx CPT, whichever you deem appropriate. The medical exam needs to be pointed to the medical diagnosis (choose a Diabetic code in this scenario – 250.xx) listed in position 1 on the HCFA form.
  3. The refraction (92015) must be pointed toward a refractive diagnosis.
  4. The claim, in its entirety with the exam, refraction and any special testing if applicable (92250 Fundus photos if medically necessary), will be filed to the health insurance carrier for consideration.

Note: You do not have to collect any co-pays at this visit.

The health insurance is going to process the claim as primary and they are going to pay based on the patient’s coverage for that service. Once the health insurance processes the claim, you will receive the explanation of payment (EOP). After the health insurance company processes the claim as primary, the claim can then be filed to VSP under their coordination policy.

Keep in mind that this secondary claim to VSP must mirror the primary claim exactly. This is not just sending the refraction code to VSP. The CPT codes and diagnosis order cannot be altered.

Once VSP gets the secondary claim, they will pay up to $66 on Signature or Choice plans, less the copay amount per the patient’s plan. VSP will not pay on any testing overages the primary does not cover. They will only pay on the exam and refraction overages that the health insurance carrier does not pay.

COB Max COB Payment for all states as of 04/01/13:

VSP COB

 

 

 

 

Let’s say they have a $30 copay from the medical insurance and the $XX refraction is non-covered. Per the health plan, the patient’s total out of pocket should be $30 + $XX for the refraction.

Next steps – this is taken directly from the VSP Coordination Policy (click on the link for the policy):

For Paper Claims:

  • When you receive payment from the health plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

For Electronic Claims:

  • When you receive payment from the health plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

After the claim is submitted to VSP as secondary and when VSP considers the claim, they are willing to pay up to $66 ($66 less the $XX VSP copay) as secondary. Of the $30 + $XX balance that is outstanding from primary, VSP will cover their portion and the patient responsibility will be what is left, if anything.

Please Note: There is no VSP write-off when VSP is acting as secondary. The primary health insurance allowable will be honored, but VSP requires no additional write-off on a medical coordination; it is a flat benefit amount as secondary.

Explaining this to the patient can also be a challenging situation, but Dr. Neil Gailmard just had a very good practice management explanation of this situation along with a handout to use with patients. I have copied and pasted this explanation from his post, but you can also access this online at:

http://www.optometricmanagement.com/om_mtotw.aspx

Optometric Management Tip # 561 – Wednesday, December 05, 2012

A Patient Handout for Vision vs. Medical. In last week’s article, I provided an overview of the differences between vision plans and medical insurance. If your practice routinely bills all eye exams to vision plans, you may want to consider differentiating medical eye exams from routine vision exams and billing the former to medical insurance plans. 

The difficult part of this process is educating patients about the differences. That requires significant staff training, but a patient handout like the one below can be a big help. Feel free to modify the form below to describe your office policies. The handout can be given to patients at check-in or check-out and it serves as a guide for staff members as they speak to patients over the phone. I find it is best to keep educational handouts short and simple. Many patients simply will not read a form if it is long and wordy.

***Sample Handout***

About Your Insurance. There are two types of health insurance that will help pay for your eye care services and products. You may have both and our practice accepts both: 
Vision care plans (such as VSP and EyeMed)
Medical insurance (such as Blue Cross/Blue Shield and Medicare).

Vision care plans only cover routine vision exams along with eyeglasses and contact lenses. Vision plans only cover a basic screening for eye disease. They do not cover diagnosis, management or treatment of eye diseases.

Medical insurance must be used if you have any eye health problem or systemic health problem that has ocular complications. Your doctor will determine if these conditions apply to you, but some are determined by your case history.

If you have both types of insurance plans it may be necessary for us to bill some services to one plan and other services to the other. We will use coordination of benefits to do this properly and to minimize your out-of-pocket expense.

We will bill your insurance plan for services if we are a participating provider for that plan. We will try to obtain advanced authorization of your insurance benefits so we can tell you what is covered. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays or non-covered services as allowed by the insurance contract.

I have read and agree with these policies.

________________________            __________

Patient signature (parent if child)                Date

Please provide your insurance cards to our staff member.

Best wishes for continued success,

Dr. xxx, O.D.

A special thanks to my business partner, Dr. Tamara Kuhlmann, OD, MS, FAAO, and Branda Barton of Optometric Billing Solutions for their assistance with this article.