Questions to ask the insurance.pdf

Questions to Ask the Insurance Company When Verifying Benefits: Medical Benefits: Is there a deductible? Does it apply for a specialist office visit? How much of the deductible has been met? What is their specialist copay? Or do they have coinsurance? Is a 92015 (determination of refractive state)...

Questions to Ask the Insurance Company When Verifying Benefits: Medical Benefits: Is there a deductible? Does it apply for a specialist office visit? How much of the deductible has been met? What is their specialist copay? Or do they have coinsurance? Is a 92015 (determination of refractive state) covered with a medical diagnosis? You will find that provider service representatives that verify patient (member) eligibility with medical insurance tend to assume that optometric care equals wellness, refractive, vision care, and as soon as they find out you're an optometrist, they'll start listing the patient's vision benefits. You will need to keep them focused on specialist medical benefits and whether the 92015 will be covered with a medical diagnosis. Vision Benefits: Is it administered by the medical plan or is the vision farmed out to a third party? What is their copay? How much is covered? Are they eligible NOW for an eye exam? When was their last date of service? Check the patient's eligibility information at every visit. Insurances change from year to year and even copays can increase or decrease with a new year. Sometimes patients change to a cheaper plan that carries a higher deductible. Get used to hearing your patients tell you “Nothing's changed since last year!” when it totally has. Review eligibility and coverage with the patient AT CHECK-IN so they're not expecting to pay a $30 copay only to get hit with their new $60 copay or find out they're paying out of pocket for their full exam because they haven't met their deductible for this year. When your patient has both types of insurance, who gets the bill? The key factors in determining which insurance to bill lie with the patient's chief complaint (CC), history of present illness (HPI), findings, and diagnoses. Bill the medical plan if the complaint and/or diagnosis is medical and bill the vision plan if the patient came in for a routine wellness eye exam and your diagnoses are routine, or refractive - and not medical. Help your patients know the difference: Some offices provide a ‘Vision vs. Medical’ explanation handout for patients to sign at check-in. On the next page is Dr. Nelson's vision vs. medical form modified by Craig Steinberg, OD, JD: Copays Collect all due copays when the patients are in your office. Because we're specialists, make sure you're collecting the specialist copay. Many insurances clearly delineate the specialist copay from the normal office visit copay on the front of the card, others have the same copay regardless of type of doctor. Others don't specify a copay on the card and that's deductible and coinsurance, or they just simply don't print it on the card in order to add excitement and intrigue to our otherwise normal lives. Health care coverage is trending toward larger copays and patients are paying a larger percentage of their healthcare costs, including purchasing high deductible health care plans. As Optometrists, we have a tendency to want to help our patients by devaluing our services to “save them money,” but there are a few factors to keep in mind: The first is that you are a highly educated professional, no less educated than their other doctors. The second is that it's not legal to not collect their owed amounts as it violates your provider contracts. The third, and most important, is that the reason they have a plan that costs them more at the visit is because they've opted to save that money every month on their lower premiums. Collection of copays: Some practices prefer to handle copay collection as part of the checkout process, some collect copays at check-in. This is your call to make. Copays need to be strictly accounted for in your accounting system. Collection of copays will represent about 20% to 40% of the total payment to you for services rendered. Collect copays! Not collecting copays is considered insurance fraud. From the Department of Health and Human Services Office of the Inspector General, “Anyone who routinely waives copayments or deductibles can be criminally prosecuted under 42 U.S.C. 1320a-7b(b), and excluded from participating in Medicare and the State health care programs under the anti-kickback statute. 42 U.S.C. 1320a-7(b)(7).” Collect copays! Link to source This applies not only to Medicare payers, but also those private carriers that base their regulations on Medicare rules. The same goes for the refraction fees as outlined below. As a reminder, you're not asking the patient to pay their copay, you're nicely telling them to pay their copay. “OK, we'll be collecting your $40 specialist copay today.” Collect copays! Collecting payments for non-covered services (Medicare and 92015): Collect your non-covered service fees when the patient is in your office. For Medicare patients, since the refraction - CPT code 92015 (Determination of refractive state) - is expressly stated as a separate, non-covered procedure independent of any E&M or ophthalmological service, you are required to collect the fee if you refract your patient. On the very rare occasion it is covered by a supplemental insurance, you can always reimburse the patient after payment arrives and it will save you a TON of trouble in accounts receivable and potential trouble with Medicare. If you are not billing for the 92015, Medicare can deem this as misrepresenting the value of the billed service as including the non-covered 92015 and recoup any overpaid amounts. For example, if you waive a $20 coinsurance on a $100 charge, then you're tacitly implying the value of that service is $80. Thus, Medicare should actually owe you only 80% of the $80, not $100. Collect for your 92015! This can upset some patients who have never paid for a 92015 before - ophthalmology offices often don't charge for it - but it's in the rules set forth by CMS (Center for Medicare and Medicaid Services). So collect for your 92015 and your 92310 (contact lens fitting) and accurately show it in your accounting. Coordinating Vision with Medical: Sometimes, you can bill both the vision and the medical carriers for your exam but only in a very specific way. You will need to submit your refraction to the vision plan only after the medical plan denies it. Don't bill both for the same service on the same day. Collect only the patient's medical specialist copay, if applicable. After receiving payment for the exam and a denial for the refraction from the medical carrier, submit a CMS 1500 to the vision plan along with the remittance advice (the EOB sent to you) indicating that the medical carrier paid for the exam but denied the refraction. You can charge your usual and customary fee for your stand-alone refraction or you can charge the full fee to the vision plan. They'll make a determination once they receive the claim. If the insurer has a refraction-only option in their online portal, by all means go that easier route.