Medicare Post Cataract Surgery Reimbursement form?

[Fezz]

Does such a beast exist?

Is there a form that patients can fill out and seek direct reimbursement from Medicare for their post cataract surgery specs?

[dammy05]

I'm very interested in this as well if anyone has had any success out there...

[becc971]

a place i used to work at filled out a CMS 1500 form for them, and sent it in for them so medicare would reimburse the patient. that way we didnt have to file it, and they could fight with the insurance company if they denied it it must be typed, then signed and dated by the patient!! and only sent in AFTER they have received the glasses, not before!!

[IhaveSpecialEyes]

http://www.cms.gov/Medicare/CMS-Form...0s-english.pdf but good luck with that, they are so picky it will probably never get paid.

[becc971]

also: there is no way to find out exactly what the patient reimbursement WILL be as far as i know.

[Java99]

We did this form for a customer and she just got denied because we were an "unknown supplier." She is resubmitting with our NPI # highlighted, so we'll see.

[TEdFitz]

IhaveSpecialEyes is correct.

Also, very important in mailing to correct address:

Cigna Gov-Services
P.O. Box 20010
Nashville, Tenn. 3720200

Hope this helps,
TEdFitz

[IhaveSpecialEyes]

https://www.noridianmedicare.com/dmefee/search.seam you should be able to get your reimburshment from this link.

[becc971]

a brief list of fun reasons that they'll deny claims:

~no four digit zip code after the 5 digit one
~place of service must be "office"
~diagnosis must be v43.1
~referring doctor must be the surgeon

these are just the most recent reasons we've been getting claims that are denied, the list will continue to grow

[SeaU2020]

Usually the 3 codes that must be on the claim are 367.4, v43.1, v45.6.

[becc971]

Usually the 3 codes that must be on the claim are 367.4, v43.1, v45.6.

we had one get denied recently because we used more than one? but maybe thats just the excuse they had picked that day

[EyeCare Rich]

IhaveSpecialEyes is correct.

Also, very important in mailing to correct address:

Cigna Gov-Services
P.O. Box 20010
Nashville, Tenn. 3720200

Hope this helps,
TEdFitz

Depends on your state, in the northwest, ie Washington and I believe Oregon, may be others as well, we send the 1500 form to Noridian as IhaveSpecialEyes has linked in her last post.

[CME4SPECS]

Am I correct in thinking that you must be a medicare supplier to submit the form for the patient? An NPI number alone is not enough?

[Fezz]

There is a previous thread on here that mentions that the form can only be used once? Is that correct?

http://www.optiboard.com/forums/show...e-Optical-Shop

Thank you all for the help!

[Fezz]

Depends on your state, in the northwest, ie Washington and I believe Oregon, may be others as well, we send the 1500 form to Noridian as IhaveSpecialEyes has linked in her last post.

Is the 1500 form better to use than the CMS-1490S form?

[TEdFitz]

...attached to itemized bill of services rendered with tax id #, supplier mailing address, supplier physical address, and finally, proof of that unicorns exist.

This IS a beast!

[becc971]

Since @fezz has brought up this lovely insurance topic anyway, does anybody know about them covering AR, progressives, and transitions? we have always been told *and told the patients* that medicare will cover the cost of a basic FT-28 and $50ish dollars on their frame, all of the overage (i.e. poly and up, trans, ar, prog upcharge) comes out of their pocket. But then one of our billing people told us this may not be the case anymore? bueller??

/hijackedsorryfezz!

[TEdFitz]

Reimbursement usually involves around 44 dollars, per lens, per eye(s) that has had the surgery...Up to 60 dollars for a new frame. Next, throw into the mix a secondary insurance, a patient might get more.

[CCGREEN]

At this point in time Medicare in my region is "Allowing" $74.37 (V2020 Standard Frame) toward a frame. (notice I did not say they are paying. They generally pay 20% less then what they "Allow") so we really end up getting $59.49 for a frame. The patient pays us the difference between $74.37 and what the frame sells for. (V2025 Deluxe Frame). The 20% that Medicare does not pay we submit to patients secondary insurance. If they do not have a secondary eventually they will get a bill for what does not get paid for by any insurances.

For lenses Medicare only allows for bare bones CR-39 and FT-28 bi or trifocals. Sometimes we can get them to pay for a Ft-35 bi or tri after we struggle with it. But NO extras of any kind. No tint, no thinner light weight lenses, no progressive, no transitions all of the "Extras" are on the patient. Medicare will pay toward UV. How much they will pay towards the lenses is based on what the Rx is. It is selected from the V-code chart.

As I understand it and the way we file it is AFTER cat. SX the patient will have one year to take advantage of Medicare benefits. ONE, yes I said ONE frame only. And if vision changes as the eye heals you might get a second set of lenses if needed. Our experience has been that Medicare will not pay for a frame if it does not have Rx lenses put into it. If the pt comes out of SX not needing any glasses and wants to buy a pair of PL Costa's, Maui Jim, Ray Ban sunglasses or any other kind Medicare will not pay for that.

We have had to fight them tooth and nail just to get payment on the basics. We cannot collect any money from the patient for their share until the day they come get their glasses. It seems as though Medicare looks for any reason to reject the claim or ask for more more information to delay payment and keep the money in their bank longer. This being a OM D's office with a dispensary we have no choice but to file for the patient.

"And that's how it is" at this office in Panama City Florida.

[Bev Heishman]

Am I correct in thinking that you must be a medicare supplier to submit the form for the patient? An NPI number alone is not enough?

Yes, you are correct. They will not reimburse a patient.

[Fezz]

Yes, you are correct. They will not reimburse a patient.

Is this across the board or are there circumstances when they will reimburse the patient directly?

[TEdFitz]

The .pdf form above is for direct patiet reimbursement...Patient pays office for eyeglasses after surgery, form is filled out, attached to an itemized bill, and sent by USPS to Medicare la-la land. In a perfect world, the patient will be reimbursed... directly...in about 2-12 weeks. Sometimes, the patient will return to office because they've recieved a notice detailing why the claim has been rejected. Other times, the patient drops in to rub their fat checks in your face.

[Fezz]

The .pdf form above is for direct patiet reimbursement...Patient pays office for eyeglasses after surgery, form is filled out, attached to an itemized bill, and sent by USPS to Medicare la-la land. In a perfect world, the patient will be reimbursed... directly...in about 2-12 weeks. Sometimes, the patient will return to office because they've recieved a notice detailing why the claim has been rejected. Other times, the patient drops in to rub their fat checks in your face.

Thanks for confirming that. Any idea on the post that I made where I referenced that a patient could only use that once?

This is a BEAST. A big PIA BEAST!

[TEdFitz]

Once. Might be in the pt.'s interest to wait on filing until both eyes are done, w/in reason. Think of it this way: 2 pieces of paper, an envelope, and a forever stamp. Hand to patient. Wash hands.

[CME4SPECS]

where is this form that you are talking about?

The .pdf form above is for direct patiet reimbursement...Patient pays office for eyeglasses after surgery, form is filled out, attached to an itemized bill, and sent by USPS to Medicare la-la land. In a perfect world, the patient will be reimbursed... directly...in about 2-12 weeks. Sometimes, the patient will return to office because they've recieved a notice detailing why the claim has been rejected. Other times, the patient drops in to rub their fat checks in your face.