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Thread: Eyemed... Yet again

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    Master OptiBoarder tx11's Avatar
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    Question Eyemed... Yet again

    Any DEFINATIVE answer on whether or not we can file Frame only? Not file on the lenses at all. order lenses from our choice of labs, charging the patient their normal copay and upcharges. Leaving the pts lens benefit unused ( no reimbursement from eyemed lab at all to avoid higher chargebacks).
    Last edited by tx11; 01-27-2014 at 06:35 PM.

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    Compulsive Truthteller OptiBoard Gold Supporter Uncle Fester's Avatar
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    Please don't take this as snarkey.

    Did you or your employer sign a contract that said you would use their lab?

    There's your answer but of course you're allowed to be as footloose and fancy free as you want. Just be prepared for the consequences if caught in an audit.

    If you have any doubt you really should have an attorney review the contract with you. You are bound to it.

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    Master OptiBoarder tx11's Avatar
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    Hey Uncle Fester your answer was not snarkey at all. To tell you the truth I really don't know what the contract says (I did not sign it). I know that in order to file a claim on the lenses you must use your chosen eyemed lab.
    Last edited by tx11; 01-27-2014 at 06:33 PM.

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    I have called them and posed the situation to where a pt cant give up glasses for 2 weeks aND THEY SAID BY ALL MEANS YOU CAN PULL A FRAME ONLY BENEFIT

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    Compulsive Truthteller OptiBoard Gold Supporter Uncle Fester's Avatar
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    Quote Originally Posted by Slim View Post
    I have called them and posed the situation to where a pt cant give up glasses for 2 weeks aND THEY SAID BY ALL MEANS YOU CAN PULL A FRAME ONLY BENEFIT
    I'd still be wary. This question is posed as an infrequent request and answered by someone I'll bet not making much more than minimum wage.

    Eye Med is not in this to see any extra money go anywhere but to them.

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    OptiBoardaholic OptiBoard Silver Supporter
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    I am not sure about the frame only claims. But we sell a lot of Shamir Auto III, Relax, and Golf lenses at my practice. Out "Eyemed" lab doesn't offer these products so in effect nearly all of our claims are being submitted via paper and our lenses are being made at our normal lab. Eyemed has approved this behavior since thier lab cannot satisfy the patients needs.

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    If you go by the In office lens program PDF online, it states that you are "required" to order the Lenses from an Essilor Lab ==> IF you want the additional $7 lens fee for using your own lab.

    I haven't tried it TX11, but will their website even allow you to just bill for a frame only?
    Why not just call them, ask them and document the conversation?

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    Has anyone been doing this? Will billing just for frame and exam benefits be ok or would this trigger some audit? It would be much better to collect the copays and edge the lens in house.

    The eyemed reps never give clear answers and you'll probably get different responses with each rep.

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    Hmm....what if the patient ONLY wants to purchase the frame from you and the patient chooses to get the lenses made elsewhere for example? Then what are you supposed to do, not sell them the frame at all because Eyemed says the complete pair needs to be billed at the same time? If you are a provider, you can't exactly deny them their frame benefit if they are eligible right? Not being snarky - just bringing up different situations that could happen.

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    Quote Originally Posted by DrDL View Post
    Hmm....what if the patient ONLY wants to purchase the frame from you and the patient chooses to get the lenses made elsewhere for example? Then what are you supposed to do, not sell them the frame at all because Eyemed says the complete pair needs to be billed at the same time? If you are a provider, you can't exactly deny them their frame benefit if they are eligible right? Not being snarky - just bringing up different situations that could happen.
    In your example, you would no problem justifying that if ever audited by said VCP, what would be the reason(s) given if audited and you are just billing the frame only to the VCP and not the lenses as the OP suggested????

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    Quote Originally Posted by David_Garza View Post
    In your example, you would no problem justifying that if ever audited by said VCP, what would be the reason(s) given if audited and you are just billing the frame only to the VCP and not the lenses as the OP suggested????
    same day service?

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    Quote Originally Posted by David_Garza View Post
    In your example, you would no problem justifying that if ever audited by said VCP, what would be the reason(s) given if audited and you are just billing the frame only to the VCP and not the lenses as the OP suggested????
    That's the thing. I don't know - why wouldn't one be able to say "the patient only wanted to purchase the frame from me and wanted to get the lenses from somewhere else" - maybe because they were cheaper or better quality than from the Luxx lab for example? Or are you as the provider supposed to deny the entire transaction altogether if the patient doesn't want to get the frame and lenses at the same time? I just find it hard to believe that they won't let you bill frame only if that is what the patient chooses to do. Again not being snarky - just curious. I don't sell materials so I don't know the answers to these questions either.
    Last edited by DrDL; 03-04-2014 at 01:47 PM.

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    Master OptiBoarder optical24/7's Avatar
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    Not speaking for David, but I think what he was getting at is that an occasional frame only would probably not be a problem (pt broke a frame, used his old lenses in new), to where routinely doing it would probably trigger an audit.

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    Our offices have billed EyeMed for the frame and contacts benefit and in this case, patient pays for the lenses out of pocket and we are able to use a private lab. They don't require you to use their lab for frame only claims.

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    Master OptiBoarder DanLiv's Avatar
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    I don't know what the contract says either (don't want to, thankfully not my baggage), but I find it hard to believe any insurance can control what you do in private transactions. If you don't bill the lenses, Eyemed should have zero say over your lens transaction. In fact, if the frame and lenses are on separate bills in your system I would deny any insurance access to my patients' private transactions unless it is demonstrated I am required by contract to disclose. When you and your patients use insurance, the obvious clause is the insurance has the option to review all the data on the transaction. If you do not bill insurance, it is a private transaction and I believe the insurance should have zero right to the info. Been a long time since I numbed my brain reading HIPAA but I thought health information can be released either to provide care or for billing purposes. If we aren't billing insurance there are no billing purposes, and of course they have nothing to do with care.

    That's the way I play it. My doc's on board. Hopefully he read his contract, and if he's not concerned neither am I.

    You can very easily pull and submit frame only claims electronically with Eyemed, and I do so routinely. A biggie I run into is we make Chemistrie in house, which of course can't be done at the insurance lab and requires me to edge, so that's a typical conversion for us. Plus the hundreds of previous Eyemed patients we have that now can't get archived lenses as they have for years. My private lab also offers me better warranties than the insurance lab, which I can offer to my patients. There are many reasons why a patient would (and should) transact privately with you and forgo the insurance. To make rock solid sure everything is above board, just be sure your patient understands and agrees that they are opting out of using the insurance, and are instead dealing with you privately. If you want to be super paranoid even give them a positively worded form to sign that thanks them for allowing you to provide your own superior and personal private service, and acknowledging that insurance will not be billed for the lenses. Heck, even include a stipulation that you will protect their privacy and NOT disclose their information. If the insurance ever asks to see something other than what was billed, you give them a copy of the form, and a middle finger. Sure your doc may bend and grab ankles if they threaten to drop you, but unless you are contractually obligated I wouldn't give them anything. And if you are not obligated, and they drop you, I think that makes for a decent suit. Contracts go both ways.

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    Quote Originally Posted by DanLiv View Post
    I don't know what the contract says either (don't want to, thankfully not my baggage), but I find it hard to believe any insurance can control what you do in private transactions. If you don't bill the lenses, Eyemed should have zero say over your lens transaction. In fact, if the frame and lenses are on separate bills in your system I would deny any insurance access to my patients' private transactions unless it is demonstrated I am required by contract to disclose. When you and your patients use insurance, the obvious clause is the insurance has the option to review all the data on the transaction. If you do not bill insurance, it is a private transaction and I believe the insurance should have zero right to the info. Been a long time since I numbed my brain reading HIPAA but I thought health information can be released either to provide care or for billing purposes. If we aren't billing insurance there are no billing purposes, and of course they have nothing to do with care.

    That's the way I play it. My doc's on board. Hopefully he read his contract, and if he's not concerned neither am I.

    You can very easily pull and submit frame only claims electronically with Eyemed, and I do so routinely. A biggie I run into is we make Chemistrie in house, which of course can't be done at the insurance lab and requires me to edge, so that's a typical conversion for us. Plus the hundreds of previous Eyemed patients we have that now can't get archived lenses as they have for years. My private lab also offers me better warranties than the insurance lab, which I can offer to my patients. There are many reasons why a patient would (and should) transact privately with you and forgo the insurance. To make rock solid sure everything is above board, just be sure your patient understands and agrees that they are opting out of using the insurance, and are instead dealing with you privately. If you want to be super paranoid even give them a positively worded form to sign that thanks them for allowing you to provide your own superior and personal private service, and acknowledging that insurance will not be billed for the lenses. Heck, even include a stipulation that you will protect their privacy and NOT disclose their information. If the insurance ever asks to see something other than what was billed, you give them a copy of the form, and a middle finger. Sure your doc may bend and grab ankles if they threaten to drop you, but unless you are contractually obligated I wouldn't give them anything. And if you are not obligated, and they drop you, I think that makes for a decent suit. Contracts go both ways.
    Ok this. You could not have stated it better. I agree 100% - EyeMed has no right asking for info regarding transactions outside their billing system. The 'disclosure form' would be a nice thing to give to patients to reassure them as well.

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    Quote Originally Posted by DanLiv View Post

    You can very easily pull and submit frame only claims electronically with Eyemed, and I do so routinely. .
    How do you do that? From everything I have seen, frame only claims must be submitted by paper. Thanks!

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    Master OptiBoarder SeaU2020's Avatar
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    I just had an EM that said on the authorization that I can use any lab....when I checked the reimbursements for the rx, there ARE NONE! The "catch" is that if you bill it, and get audited later, they will not like it if you don't use EXACTLY what you "billed" for. The solution is simple...don't "bill" it. This is my favorite EM, the Access Plan!
    ~~ There's a battle between what the cook thinks is high art and what the customer wants to eat ~~

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    Master OptiBoarder AngeHamm's Avatar
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    Frame Only patienst aren't nearly the problem that Lens Only patients are with the new EyeMed system.
    I'm Andrew Hamm and I approve this message.

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    Compulsive Truthteller OptiBoard Gold Supporter Uncle Fester's Avatar
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    Quote Originally Posted by AngeHamm View Post
    Frame Only patienst aren't nearly the problem that Lens Only patients are with the new EyeMed system.
    Get a copy of the 3 page formal "Eye Med Policies".

    Highlite parts that require a signed statement that they are aware they cannot cancel after submission, traced lens only orders are only private pay and if the lens choice or other option is not available in the portal it is not included in the plan. Period!

    We made up a brief statement emphasizing the cancellation policy and require them to sign and date it. If they don let them walk.

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    Master OptiBoarder AngeHamm's Avatar
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    Quote Originally Posted by Uncle Fester View Post
    Get a copy of the 3 page formal "Eye Med Policies".

    Highlite parts that require a signed statement that they are aware they cannot cancel after submission, traced lens only orders are only private pay and if the lens choice or other option is not available in the portal it is not included in the plan. Period!

    We made up a brief statement emphasizing the cancellation policy and require them to sign and date it. If they don let them walk.
    The patients aren't the problem at all. The rigidity of the new EyeMed policies are the problem. Hell, even Davis Vision lets me order uncut lenses for my patients who want to keep their old frame. If you're going to require that I send frames for edging, EyeMed, you need to either A) cover two pairs of glasses for your clients so they always have a backup pair, or 2) [or B)] cover frame and lens every 12 months in every plan.
    I'm Andrew Hamm and I approve this message.

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    Master OptiBoarder OptiBoard Gold Supporter Judy Canty's Avatar
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    Of course, the real goal may well be to drive their members to a one-hour location where there is no need to give up a frame for very long at all. "GASP"

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    SO TRUE! And... we have one down the street from us!

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    Master OptiBoarder DanLiv's Avatar
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    Quote Originally Posted by Aurelie View Post
    How do you do that? From everything I have seen, frame only claims must be submitted by paper. Thanks!
    When pulling the auth you may select from exam, contact, frame, lens, and "frame & lens". Just pull exam and frame only, or go back and edit the authorization to change to exam and frame only. Easiest auth system of all the insurances.
    Click image for larger version. 

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    Compulsive Truthteller OptiBoard Gold Supporter Uncle Fester's Avatar
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    Quote Originally Posted by AngeHamm View Post
    The patients aren't the problem at all. The rigidity of the new EyeMed policies are the problem. Hell, even Davis Vision lets me order uncut lenses for my patients who want to keep their old frame. If you're going to require that I send frames for edging, EyeMed, you need to either A) cover two pairs of glasses for your clients so they always have a backup pair, or 2) [or B)] cover frame and lens every 12 months in every plan.
    Not sure if you've seen the EM policy but it states that if a patient calls after submission and wants to change or cancel the order (even seconds after the submission) and you do not have a signed document of the "no changes/cancellation allowed of the order post submission", Eye Med will side with the patient. You will now be billed as a private pay order. I assume that means they will withhold or deduct from future reimbursements whatever they paid you for that order.

    I think Eye Meds people got tired of upset patients complaining of the rigid no cancellation policy so they made us look like the bad guy when informing the patients of their policy. What a surprise!

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