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4 ways to change your thinking-and your reimbursement


A consulting client had a few questions about a patient who came into her office. A contact lens patient wanted to use his Spectera third-party coverage, and the receptionist told him it was no problem.

The views expressed here belong to the author. They do not necessarily represent the views of Optometry Times or UBM Medica.

A consulting client had a few questions about a patient who came into her office. A contact lens patient wanted to use his Spectera third-party coverage, and the receptionist told him it was no problem.

The first problem was the office policy of requiring the patient’s Social Security number (SSN) on the intake form, which displeased the patient.

The second problem was how the doctor chose to bill and code the exam. During the course of the exam, the doctor learned that the 74-year-old patient not only had macular degeneration but blepharitis. I’m sure you can see where this is going.

The doctor billed Spectera for a required (in her thinking) dilated exam with a $35 charge for photography, totaling a $110 reimbursement with $65 of that to show up at a later date.

The doctor next gave the patient his Rx and said she’d see him next year for his annual exam.

She wonders what she could have done differently. I found four ways this patient encounter could have gone better.

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1. Don’t bother with the SSN

The first piece of advice I offered this doctor is skipping the required patient SSN. This requirement only pisses patients off and makes them think you’re up to something. Unless you absolutely have to have the SSN (for example, if an insurance company requires you to include it), I wouldn't even bring it up. It's just a fight you most likely don't need to have, and it breeds ill will from the beginning. Such a fight may cost you a patient forever over information you don't need, so just take that line off the form.

Next: Always obtain medical carrier information


2. Always obtain medical carrier information

Next, always, always, always obtain the patient's medical insurance (even if you aren’t using it). Inform the patient via the intake form that it is possible his visit will be billed to his medical insurance-you won’t know what’s in the eye until you look. There’s no way on this Earth that a 74-year-old patient’s exam shouldn’t be billed to medical as the primary coverage. The incidence of eye disease in the elderly population is just too high.

That's not to say that you can’t use the Spectera in addition to Medicare to cover the contact lens fit. Just to give some perspective, here is what the examination should have paid:

92004: $120ish

92250: $70ish

Spectera CL fee: $75

(Technically, you could charge a 92015, but I’d just consider that part of Spectera’s fees.)

Total billing is $265 vs. the $110 the doctor got paid.

Dropped revenue adds up quickly with differences like this. If you misbilled like this once per day, it makes a yearly $50,000 profit difference. In other words, you'd lose $50,000 income for no reason. That’s with only one of these per day.

Next: Know your third-party contracts


3. Know your third-party contracts

It’s your responsibility to know what your accepted plans cover and what they don’t. After all, you signed the contracts to provide these services at an agreed-upon reimbursement.

Spectera doesn't “require” dilation (unless the contracts have drastically changed their wording)-the contract just says Spectera covers it. Here’s the problem with that: if the patient has medical history which necessitates a dilated fundus exam (such as diabetes, hypertension, high myopia, advanced age, etc.), Spectera should not be billed as the primary insurance. Such cases should always be billed to the medical plan.

It doesn’t matter what Spectera covers because you have a contract with Medicare as well. CMS rules state that you cannot assign benefits (meaning let someone else pay whether it’s Spectera or even allowing the patient to private pay) for Medicare-covered services. An eye exam in which the patient has cataracts, macular degeneration, diabetes, hypertension, blepharitis, or any other medical condition is most definitely a Medicare-covered service.

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4. Schedule appropriate follow-up visits

Following a patient appropriately, especially an elderly patient, is a key part of our jobs.

The patient in this example has macular degeneration and blepharitis. Those conditions alone-all covered by Medicare-should warrant at least two additional yearly visits to properly monitor. If the patient had secondary medical insurance, he likely would have had zero out-of-pocket expenses.

Next: Change your thinking-and your billing


Change your thinking-and your billing

We have to get out of the typical OD mindset in which we’re performing quickie vision exams, handing patients a piece of paper, and telling them, “See ya next year.”

Let's take just this one patient as our example.

On this visit alone, the doctor lost $155. I would have seen the patient at least two more times this year to follow up for the blepharitis and age-related macular degeneration. I might also include photos at the six-month mark if I see clinical changes. Those two visits would run somewhere in the neighborhood of $65 for a 92012, so a minimum of $130 additional exam fees from this one patient.

So, this didn't lose $155-she actually lost $285. That gets pricey if it becomes a regular billing practice.

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This principle holds true for most ocular conditions. Glaucoma suspects, diabetics, allergy patients, dry eye-all of these patients should be both billed to medical and scheduled appropriate follow-up through the year if you intent to provide a level of care commensurate with the conditions these patients have.

As an aside, be careful if you are charging a certain fee for screening photos. Make sure that you document that you are billing only for the technical component of the photography. Remember that third-party payers cover a combined reimbursement for the technical component and the professional component, the latter including a separate interpretation and report.

Third-party payers don’t care what you charge as long as your fee is consistent for covered patients as well as private-pay patients-meaning you aren’t charging covered patients more.

So, ensure that your documentation shows that you aren’t billing a full 99250 and charging only for the technical component, not the professional interpretation. Semantics is more important than you think with third-party payers. Take the extra few minutes to get it right so you aren’t inadvertently reducing the fees to which you’re entitled.

Remember these four changes to better improve your patient care and get paid for the services you’re providing.

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Carole Burns, OD, FCOVD
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