Aphakic Contact Lens Billing

**eyegirl** · 03-14-2006, 09:21 PM

Does anyone have any idea what your policy is on billing for aphakics?

We have had SEVERAL new fit aphakics lately, and a lot of the insurances are paying pennies on the dollar IF THAT, and then claiming the rest is provider right off, even when we dispute it.

We are in Michigan, and deal with a lot of BCBS and Priority Health claims. We've already spoken to the insurance reps, and the next step according to the insurance company is to bring it to the Michigan Ophth. Society.

Anyone have a particular policy? We hate to have the parents pay for it, as it really should be covered benefit, but we can't keep this up!

Do you have a benefit waiver that that they sign before ordering? Do you have them pay up front before billing? How well is that received by the parents if so?

Chip - what do you do?

**chip anderson** · 03-14-2006, 10:02 PM

Get patient to pay me. Fill out his forms and let him fight it out with his insurance people.
Personally I charge a flat rate for fitting and a flat rate for replacement. Fitting fee includes any changes needed in first 90 days.

Also note: I have had a few insurance negotiators call me in the last few days wanting to negotiate fees for prosthetic eyes already delivered. I tell them, let me in the networK (they won't let non-physicians in) or give me an exclusive on all the prosthetic eyes you are are paying for in Mississippi (I am the only independent provider) and we'll talk. In each case, they shut-up and I received a check for full to 80% within two weeks.

You have to reguard your services as being worth what they are worth. Stop trying to be the one who came in at low bid and ended up working for nothing.

Chip

**eyegirl** · 03-14-2006, 10:15 PM

Do you find that parents are alarmed at the CL prices?
We're starting to do more RGP fits now, but in the past he's chosen Silsoft or Continental's ped's aphakic.
I've seen 2 bilateral aphakic babies in the past month come through the office.

I just can't imagine the parents paying outright for that. Don't they ask about insurance?

Are you able to get out of billing the insurance, because you are not a listed provider with their insurance?
I've suggested we collect payment up front from the parents, but billing claims that we can't do that without a signature release. Apparently if the parents complain to the insurance company, we would be accountable for not billing directly to the insurance.

I think I already know the answer to this next question, but what's your lens of choice for aphakic babies?

**chip anderson** · 03-15-2006, 07:01 AM

Lenses for infants are hard to answer. So many of the aphakic infants I see don't have insurance, other than state programs. There are so few soft pediatric powers/fits available one doesn't have much choice. While RGP's are in some ways the lens of choice it's difficult to get a positive result because of the difficulties in measuring the patient, evaluating the fit, growth of the eye, rapid changes in corneal shape and Rx, infants loosing the lens, ect. I am not sure that I would recommend same. The really big problem with early pediatric fitting is getting the patient/parents to stick with it. So many of them stick around for a period of time and lose interest due to the drugery, the expense of lenses, etc. Then eye return when it is too late to recapure much acuity from the eye (you get the blame of course) that this part of one's practice can be most discouraging. It these cases I suppose consumer education really is the answer. Unfortuantely in our area we have too many infants whose parents occupation is having babies and collecting checks and couldn't be educated with electroshock therapy to get thier attention.

Chip

**eyegirl** · 03-15-2006, 08:36 PM

The problem is that like you said most of the babies have some sort of state plan, or otherwise, and the parents don't want to or can't afford to pay for the contacts first. We had another baby come in yesterday who is in foster care and also has bilateral cataracts. This foster mom is wonderful but I don't think she would be able to afford $400 worth of contacts while she waited to get reimbursed. You know what I mean?

It's so frustrating, because the doctors want these babies to see, the parents want these babies to see, but the insurance companies don't want to pay for it.

Grrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr rrrrrrrrrrrrrrrrrrrrrrrrrr:angry:

**chip anderson** · 03-15-2006, 09:06 PM

If the parents want the children to see, they should provide for them. It's what parents, not some third party do. If they don't provide for them, they should not be parents. I do understand when parents have catastophic expense such as $100,000 preemie care or such they cannot be expected to provide this early in life. But $400.00 is not a devastating expense.

Chip

**eyegirl** · 03-15-2006, 09:16 PM

Unfortunately there are several children we see in foster care because of the parents not providing. If the bio parents won't even bring their child into the eye doctor they probably aren't going to pay for the contacts. We can't expect the foster family to pay up before we order either.

It's really a sticky situation. We usually end up ordering the contacts regardless and trying to collect payment from the insurances. It's just frustrating when they expect that $7 should cover the expense in full.