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The Optometric Billing Spot

By Blog Owner 17 Jul, 2017

Melanie Denton OD, MBA, FAAO recently wrote and article for optometry times relating to the "insurance game". She is 100% right...INSURANCE IS A GAME and unless you learn the rules your practice will never be as successful as it could be, it's just that simple.

One of the biggest things she points out is sometime I've been telling clients for years: when it comes to your insurance billing it's important to STAY INVOLVED! This doesn't mean to hang over your biller's shoulder and check every little thing they do. It means learn and understand the process and the intricacies so that you can have informed and intelligent conversations with your biller and/or the insurance companies. If you know how things work, you'll be that much better prepared to check up on things, make adjustments when things go wrong and make intelligent and informed decisions about the direction your practice is going.

I have included an excerpt of her article below. You can always click the link to read the whole thing.

I know exactly how insurance is billed at my office. Is that the best use of my time?

This is how we get paid, so I think staying involved is a good idea right now when our patient load is smaller.

Staying involved is also effective in making sure that as a practice we set things up correctly. I have watched countless YouTube videos about CMS 1500 forms and how to fill them out, how to read explanation of payment forms, and clearinghouse-specific training.

Related: Defining success: Is more better?

I know how our practice management system interfaces with our clearinghouse, and often I send the claims myself. In the setup period, it is critical to be attuned to the details.

Even if your practice is well-established, it is important to spot check claims and ensure that they are completed correctly not only to ensure your revenue stream is what it should be but also to guard against potential audit concerns.

Related: Behind the scenes of Instagram practice photos

In addition, staying involved helps me to know which commercial carriers are excluding us from specific panels without telling us. (Sometimes PPO or HMO panels require a primary-care referral first or require your participation on that specific sub-panel).

There is no shortcut to setting up your office for the first time on insurance panels. The process is time consuming and at times maddening. Some of the companies we are now regularly taking payments from took six to eight months to credential us.

This is a marathon, not a sprint. Don’t take no for an answer. Fight the good fight.



By Blog Owner 01 May, 2017
Dear Readers, A quick note today:

Whenever you bill a surgical procedure to insurance (any procedure that begins with a '6') you MAY NOT bill an exam to that insurance company for the same day as insurance considers an exam to be PART OF THE SURGICAL PROCESS!

However, if you have a significantly DIFFERENT DIAGNOSIS CODE you may append the exam procedure with a -25 modifier and bill the insurance for both the exam and the surgery so long as the diagnosis code being used for surgery is ONLY POINTED TO THE SURGERY and the diagnosis code for the exam is ONLY POINTED TO THE EXAM!
By Blog Owner 24 Apr, 2017
https://www.linkedin.com/hp/update/6245619520837283841

Primary Eyecare:

"Everyone will come to you and you will be the one who refers them to different specialties". Maybe the eyes are more than just a window to the soul?
By Blog Owner 18 Apr, 2017
It has become a fact, especially since the introduction of "Obama Care", that doing billing in house is more costly than outsourcing. Not necessarily because the cost of salary is higher but because, and this is specifically unique to optometry, most new and small to medium sized practices don't have the man-power or resources to dedicate one person or a group of people specifically to the task of insurance billing. The result is that collection rates rarely exceed 73% of available money from insurance/patients. EVERY ONE of our clients achieve a 93% collection rate within 2 years; typically much faster if that practice owner is willing to let us "run the show" and defer to us when it comes to making decisions and implementing policies regarding insurance billing. This means that your practice will instantaneously be more profitable as a result of your decision to outsource which in turn means that you are spending less money doing so.

https://www.linkedin.com/hp/update/6241990175124185088
By Blog Owner 11 Apr, 2017
Problem:
"I have the same problem! I just saw the first patients that I have on
this plan. The patient has harvard with "routine vision coverage" and
deductible for medical. They also have eyemed. Harvard rejects the
92015 and discounts the 92024 by 50%. And because its not a medical
diagnosis we cant do COB with eyemed for the refraction(or so I am told)"

ANSWER:
This is actually not a "problem". Harvard Pilgrim follows Medicare guidelines In this area. Medicare does not pay for a refraction because they consider it to be part of an exam. Therefore, it is acceptable to bill all Harvard pilgrim and Medicare patients for a refraction and either NOT bill insurance for the refraction or include a -GY modifier when billing ( which MAY NOT be accepted by Harvard Pilgrim).

If these patients ALSO have EyeMed of VSP you can bill them INSTEAD of Harvard pilgrim but I do not recommend this as it can sometimes cause a patient to lose their annual exam benefit depending on their plan.

Hope this is helpful to everyone. As always, talk back to us or ask anything you want related to optometric billing!
By Blog Owner 04 Apr, 2017
Even though my answer is always "Of course", it struck me that some serious "fake news" has transpired over the last few years regarding optometric billing, nay, medical billing as a whole and I think it's time to set the record straight. So here are some marketing tag lines that you should be aware of and watch out for when shopping for a reputable company to provide you with optometric billing services
By Blog Owner 27 Mar, 2017
When performing routine eye exams on Aetna Patients it is a good idea to get in the habit of using
Z01.00 OR Z01.01 as your diagnosis code INSTEAD of a code beginning with "H52". This is because many of Aetna's plans actually are set up to pay for routine eye exams but ONLY if the primary diagnosis is = Z01.00 OR Z01.01. Even though this does NOT affect EVERY Aetna plan that provides patients with a routine eye exam, using these codes will NOT cause a denial...EVER (as long as the patient has coverage for routine services) whereas using a code that begins with "H52" does, in fact, cause denials in many cases (even when the patient DOES have coverage for routine services).

  As always, I hope you find this information both useful and informative.
By Blog Owner 20 Mar, 2017
Please find a response written to one of our clients regarding the issue of billing Routine and Medical procedures to insurance companies on the same claim/ same date of service:

Dear Dr. "X" ,

 I have noticed many, many times that when you are working with patients who have both an eye exam and vision therapy session that you are coding the entire visit as routine. This is not correct and puts us at a bit of a disadvantage here.

 It is important to note that :
92060 is NEVER covered when paired with ANY diagnosis that begins with "H52".
It is also important to NEVER include a diagnosis beginning with 'H52" in the chart of a patient who is receiving vision therapy. The reason for this is that even if you don't link the patient's procedure code to that routine diagnosis, compulink still does when creating claims. The best thing to do is to just leave the routine diagnosis out of the chart completely.
If a patient has a benefit for both routine exams AND vision therapy sessions, I strongly advise against performing both a routine exam and a vision therapy session on the same day. Many commercial payers, such as Cigna, utilize the services of foreign workers to adjudicate these types of claims and they are notorious for automatically denying valid medical claims if they even contain a routine diagnosis code on them (in fact I advise NEVER performing routine and medical procedures during the same session for the same reason) . I can not say for certain if this is due to language barriers when they are receiving their training or if they are given explicit instructions by the corporate office to make these decisions, however, the end result, 99% of the time, is that the entire claim ends up getting denied as routine even though it was most likely coded correctly. Getting this decision reversed is harder than having a letter you sent to the President of The United States personally replied to by him instead of one of his staff members.

 As always, I hope you find this information both helpful and informative. Please share it with any colleagues you deem necessary. You can also direct them to read our blog for similar information as well.
By Blog Owner 13 Mar, 2017
As optometrists you obviously know the importance of making sure people have regular eye exams...but do your patients know how important it is? More importantly, do your DIABETIC patients know how important it is?

As I've mentioned in previous article, the management of diabetic patients can be very lucrative and rewarding for you as a practitioner, both from an optometric billing stand point and a clinical one. However, you can also use this a GROWTH tool for your practice and help spread the word about the importance of eye exams to people with diabetes.

Here are just a couple of the ways you could go about this:

Partner with an FQHC clinic for referrals of diabetic patients
Set up times to go to stores, like WalMart or the local pharmacy, and give free exams to people. Advertise this in the paper to make the community aware and use that time to not only get these people to become your permanent patients but to also council them on the necessity of routine check-ups.
Partner with General Practitioners to receive referrals of diabetic patients
Did you know that 60% of people with diabetes skip having their eyes examined regularly?!?! Read the article below to find out more, and don't forget, if you ANY QUESTIONS about your optometric billing, contact opticXpress today!

https://www.aao.org/eye-health/news/sixty-percent-skip-diabetic-eye-exams
By Blog Owner 08 Mar, 2017
Owner of opticXpress begins investigation into merits of suing Vermont Health Connect.

Due to many problems statewide with Vermont Health Connect, Andrew Roy, owner of Vermont based opticXpress-a medical billing company that deals solely with the speciality of optometry, has begun looking into the possibility of opening a class action lawsuit against them after enduring his own on-going battles with the "Obama Care" organization.

Recently, Mr. Roy was told by the Health Care Advocate, a non-profit organization that specializes in issues with Vermont Health Connect, that there IS grounds for a lawsuit but that it would be extremely difficult due to the fact that it is a state agency.

In 2016, Vermont Health Connect reported to the IRS that Mr. Roy had obtained health insurance through the agency for 10 Months in 2015 when, in fact, he had only obtained 4 months worth of insurance from the despot organization. When the error was discovered in November of 2016, Mr. Roy reported the mistake to the agency who refused to accept documentation from his bank proving their error. Instead, they elected to keep the federal funds for their own use and directed him to take the issue up in a "fair hearing", which is run by an un-regulated third party who has no contact information and who only makes appointments on behalf of Vermont Health Connect at their own convenience. To date, it has been over the requisite 30 days since the fair-hearing team was supposed to reach out to Mr. Roy and no contact has yet been made with him. Consequently, Mr. Roy has been assessed a tax penalty by the IRS which must be paid, per Affordable Care Act regulations, until such a time as the debt is resolved OR Vermont Health Connect is found liable for their error.

Furthermore, Mr. Roy has decided that he will update the public on the issue and possible litigation by issuing timely press releases as well as posting copies of any relevant information in the form of articles on his medical billing blog. The purpose of this is to not only inform the public as to the atrocities that "Obama Care" has wreaked on society, both at large and in Vermont, but also so that it can be used a case study for optometrists everywhere to see exactly what kind of issues face their patients on a daily basis when it comes to both billing and dealing with insurances that are purchased through government run health insurance agencies.

In addition to this possible landmark legal case, Mr. Roy has informed the office of the Governor of Vermont and is awaiting a meeting with the Governor about this matter.
More Posts

The Optometric Billing Spot

By Blog Owner 17 Jul, 2017

Melanie Denton OD, MBA, FAAO recently wrote and article for optometry times relating to the "insurance game". She is 100% right...INSURANCE IS A GAME and unless you learn the rules your practice will never be as successful as it could be, it's just that simple.

One of the biggest things she points out is sometime I've been telling clients for years: when it comes to your insurance billing it's important to STAY INVOLVED! This doesn't mean to hang over your biller's shoulder and check every little thing they do. It means learn and understand the process and the intricacies so that you can have informed and intelligent conversations with your biller and/or the insurance companies. If you know how things work, you'll be that much better prepared to check up on things, make adjustments when things go wrong and make intelligent and informed decisions about the direction your practice is going.

I have included an excerpt of her article below. You can always click the link to read the whole thing.

I know exactly how insurance is billed at my office. Is that the best use of my time?

This is how we get paid, so I think staying involved is a good idea right now when our patient load is smaller.

Staying involved is also effective in making sure that as a practice we set things up correctly. I have watched countless YouTube videos about CMS 1500 forms and how to fill them out, how to read explanation of payment forms, and clearinghouse-specific training.

Related: Defining success: Is more better?

I know how our practice management system interfaces with our clearinghouse, and often I send the claims myself. In the setup period, it is critical to be attuned to the details.

Even if your practice is well-established, it is important to spot check claims and ensure that they are completed correctly not only to ensure your revenue stream is what it should be but also to guard against potential audit concerns.

Related: Behind the scenes of Instagram practice photos

In addition, staying involved helps me to know which commercial carriers are excluding us from specific panels without telling us. (Sometimes PPO or HMO panels require a primary-care referral first or require your participation on that specific sub-panel).

There is no shortcut to setting up your office for the first time on insurance panels. The process is time consuming and at times maddening. Some of the companies we are now regularly taking payments from took six to eight months to credential us.

This is a marathon, not a sprint. Don’t take no for an answer. Fight the good fight.



By Blog Owner 01 May, 2017
Dear Readers, A quick note today:

Whenever you bill a surgical procedure to insurance (any procedure that begins with a '6') you MAY NOT bill an exam to that insurance company for the same day as insurance considers an exam to be PART OF THE SURGICAL PROCESS!

However, if you have a significantly DIFFERENT DIAGNOSIS CODE you may append the exam procedure with a -25 modifier and bill the insurance for both the exam and the surgery so long as the diagnosis code being used for surgery is ONLY POINTED TO THE SURGERY and the diagnosis code for the exam is ONLY POINTED TO THE EXAM!
By Blog Owner 24 Apr, 2017
https://www.linkedin.com/hp/update/6245619520837283841

Primary Eyecare:

"Everyone will come to you and you will be the one who refers them to different specialties". Maybe the eyes are more than just a window to the soul?
More Posts
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