Received a question from a provider regarding Harvard Pilgrim

  • By Blog Owner
  • 11 Apr, 2017
"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)"

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!

The Optometric Billing Spot

By Andrew Roy 21 Nov, 2017
Up until recently, there have not been any effective patient-derived models in which researchers can test for treatments in regards to macular disease. However, this has possibly changed as researchers have been able to re-program stem cells with three different forms of macular dystrophy. After aging them in a dish these cells mimicked several characteristics of the disease, allowing for scientists to begin working with a human stem cell model. Rebecca Hepp dives into detail in how these research models have paved the way for innovative treatment research. How does this review of optometry affect your optometric billing?
By Andrew Roy 15 Nov, 2017
Ocular surface disease (OSD) management is driving technology to get ahead of the game. This means educating and diagnosing patients in a more timely manner in order to motivate them to start and maintain their treatment. John Rumpakis, OD, MBA, discusses how these new technological advances in imaging, though resourceful, may or may not be billable for insurance companies. How does the coding in these diagnoses affect your optometric billing?
By Andrew Roy 09 Nov, 2017
Optometry is advancing every day in this ever-changing world, and so is the world-wide industry of classic clinics. Brooke Messer, MD, explores the challenge of building a niche practice--that is, building a practice based on that of a certain specialty, such as contact lenses. This type of practice can yield great emotional and financial rewards while making connections between you and your patients. Many resources are made available at your fingertips while bringing a new dimension to the practice when beginning to train staff. Investing in technology can go a long way in building your patients loyalty. How can your optometric billing help build your specialty practice?
By Andrew Roy 24 Oct, 2017
The U.S. prevalence of glaucoma in patients is suspected to rise 6.3 million by 2050. Jarett Mazzarella, OD and Justin Cole, OD write about how integrating newer technologies into optometry practices can help detect signs of early glaucoma and how it is integral for providing data to diagnose and begin early treatments. Clinicians can use many tools such as corneal hysteresis, OCT angiography, visual field testing and electrodiagnostics to help better detect the signs and begin treating patients to prevent them from going completely blind. How does modernizing technologies for detecting disease affect your optometric billing?
By Andrew Roy 20 Oct, 2017
Advances in clinical technology are helping optometrists to sooner detect diseases that may otherwise be undetectable. Last month a patient of Paul M. Karpecki, OD, without symptoms and 20/20 vision, was found to have a significant peripheral malignant melanoma. Upgrading basic tools such as handheld instruments and refractor systems can help in the early diagnoses of most life-threatening diseases; diseases like AMD (age-related macular degeneration) or glaucoma, for instance. Optometry is embracing new innovative technology in order to improve diagnostics. How can upgrading your diagnostic tools transfer into more robust optometric billing?

Click here to read more.
By Andrew Roy 13 Oct, 2017
Optical coherence tomography (OCT) scanning has come a long way in the development of its technology in the last two decades. Through new software updates such as swept source (SS), the OCT can provide higher image acquisition speed and less variation in sensitivity. Instruments now have Anterior and Posterior Segments available for use along with enhanced depth imaging. OCT angiography allows the detection of movement to be seen at higher speeds. Dive into the world of today’s optometric technology knowing how to navigate through these exquisite tools. How will these new advances in OCT affect how you practice optometry and your optometric billing?

Click here to read more.
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

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.
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