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Thread: Preventing fraudulent billing practices on managed care plans

  1. #1
    Bad address email on file KAYDEE's Avatar
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    Preventing fraudulent billing practices on managed care plans

    Hey all,

    For those of you whom subscribe to VSP, EYEMED, DAVIS etc , I have been wondering what measures are in place to prevent fraudulent transactions from taking place.

    Thanx

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    ATO Member HarryChiling's Avatar
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    What the insurance companies pay on these plans is the only fradulent thing going on in my office, but I have heard of people billing for scratch and UV on poly lenses. I can't really say that I blame them, although it helps our office because they are constantly asking why other places charge more if they accept the same insurance.
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    Are there any measures in place?

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    Master OptiBoarder OptiBoard Silver Supporter Jubilee's Avatar
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    I am sure they have some protection in place. We have been audited by both VSP and Davis vision, and of course passed with flying colors :)

    I am sure they look at certain trends, and if they do find some practice continually charging for scratch and UV though it is standard in poly, then they will pursue it, and then ask for a refund

    Heck, I know our state medicaid office is familiar with the fact that we should not bill for UV if using a poly lens code. (We had a discussion about this and the differing reimbursement rates. Seems like for a high end rx that need poly, for example if they are a child, we getter better reimbursement by billing regular plastic and a UV coat, then for straight poly)

    Cassandra
    "Some believe in destiny, and some believe in fate. But I believe that happiness is something we create."-Something More by Sugarland

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    Manuf. Lens Surface Treatments
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    Redhot Jumper we getter better reimbursement ....................

    Quote Originally Posted by Jubilee
    Seems like for a high end rx that need poly, for example if they are a child, we getter better reimbursement by billing regular plastic and a UV coat, then for straight poly)
    Cassandra
    Then it makes more sense to sell regular CR39 and do you UV and even your scartch resistant on insurance patients.

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    Bad address email on file KAYDEE's Avatar
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    What measures do they have in place against "overservicing" and overbilling on frames.
    eg Patient wants frame X but you charge for frame Y (whch is more expensive) and give them frame X

    or Optom charges for spex with lenses but gives patient something else in place such as sunglasses or other product not covered by the plan.

    or a claim is submitted for two members of the plan and the total combined amount is then used for one dependent whom orders lenses, sunglasses, contact lenses and get a voucher to use at the local mall

    or claims being made when no patient was actually seen

    Do they have measures in place against that ?

    Please don't think I have a devious plan up my sleeve, its purely for interest sake as we have similar plans at home with some rather disturbing anti-fraud measures in place.

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    OptiWizard
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    VSP usually audits records. About once a year I get a request for mailed copies of 10 records including frame and charges. Larger accounts get an in-person audit.

    One of my employees used to work for an insurance company. She said they had a much bigger problem with dentists overbilling.

    Harry

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    OptiBoardaholic
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    Our experience has been that if you mistakenly add UV charges for poly, VSP's eyefinity website will catch the mistake and stop you even before you generate the charge sheet. Same thing for any other option that either doesn't exist or is not needed.

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    What happens after a VSP audit?

    My office had an in-office audit about two weeks ago. What happens next? If my office fails the audit, do I get booted off the VSP panel right away or do I get a chance to make corrections? What's the normal protocol? Or does everything depend on how severely my office fails the audit? (e.g. 20% vs. 70% on the charts). Any light on this topic would be greatly appreciated.

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    Master OptiBoarder
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    [quote=

    what measures are in place to prevent fraudulent transactions from taking place.

    [/quote]


    If you mean in office, I check all billing to make sure it wouldn't even be percieved as fraudulent. If you mean on their end, I assume they check also as I have gotten phone calls when they misunderstand billing.

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    Quote Originally Posted by Eyeball View Post
    My office had an in-office audit about two weeks ago. What happens next? If my office fails the audit, do I get booted off the VSP panel right away or do I get a chance to make corrections?

    I have been dealing with VSP for over 20 years. I have never had an in office audit but I understand that you do get a chance to make corrections. They can't boot you off without an appeal anyway.

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    Do enough of it, make a habit of it and you can get a visit from your state attorney general.

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    Master OptiBoarder OptiBoard Silver Supporter Jubilee's Avatar
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    If you fail their audit, then they will proceed with a more indepth look at your practices. They will ask for a plan to correct the issues, and will revist later to check to see all is well.(probation)

    If upon their follow up visit you don't pass and aren't in line to pass.. then you will get booted off.

    Cassandra
    "Some believe in destiny, and some believe in fate. But I believe that happiness is something we create."-Something More by Sugarland

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    Master OptiBoarder rep's Avatar
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    Wake Up People

    It's called INSURANCE FRAUD and the state and federal authorities take a very dim view of this.

    You won' t be caught by VSP or any other company. The person who turns you in will be the little old lady or little old man who thinks your ripping them off and they will take it to the law.

    Rep

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    Rep is right. VSP doesn't do much. I did have some doctors in my territory loose VSP (temporarily) because of fraud. But VSP and these other insurances care more about making sure the EXAMS are audited and thourough to avoid possable liable. The dispensaries are rarely looked at.

    Aaron

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    On a related note isn't eyewear/exam coverage a defined benefit program not an "insurance" program and thus not be within the jurisdiction of insurance fraud investigations?

  17. #17
    Master OptiBoarder
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    Depending on who does the billing in offices is the main key in this debate. In large MD/OD practices some of the individuals I have come across who do the billing, are not opticians and will not listen to anyone else but the coding expert they attended and met at a seminar.

    When the billing person calls a DMERC Region office for clarity on a policy the person answering the questions is often less knowledgeable. It creates a vicious cycle between an optician who knows better and an individual with little knowledge encouraged by an inappropriate way to handle things.

    If you are an optician who has experienced this, my recommendations are to cover your self and document discussions as well as the date so it doesn't come back to you when an audit occurs.

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