Process of Billing Insurance and Office Questions

[eyepeople]

Hello Everyone,

We are moving to a new location soon and hiring a doctor, as now we are a vision boutique and we are becoming a one stop shop. We are applying to take both VSP and EyeMed insurances, and this is something that we do not have experience with. We are also in the midst of getting a new EHR and we are looking at Revolution as our top choice as of now. We have seen demos on quite a few, and they raise more and more questions, so any help would be appreciated!

Though our new office has not yet opened, here is the information I can provide as of now: We are starting with one part time doctor (2-3 days/week), going up to full time once we kick off. Our area has ample foot traffic in a major city. We currently have an owner who will be working on the floor, one full time optician, and one part time.

-What is the process of filing insurance for VSP and EyeMed? If someone is to be billed medically, is the process much different?
-Is filing insurance a simple task with our staff load? Do you have a dedicated insurance biller? Time this takes for an employee to be on top of?
-What is a "Clearing House Fee", and what do they typically run?

Thank you for your insight!

[pknsbeans]

-What is the process of filing insurance for VSP and EyeMed?
Straightforward. You will need to be credentialed in all insurances you want to take. VSP (though they seem to be loose with corporate retail) will require the doctor to own a certain percentage of the optical. EyeMed is easy. You will need the doctor to be credentialed as well. The only tricky part of filing claims is to make sure you are collecting all appropriate copays, since it may be itemized more than your current pricing structure.

If someone is to be billed medically, is the process much different?
YES. I highly recommend Medical Optometric Care by Drs Mike Sandy and Steve Nelson.

-Is filing insurance a simple task with our staff load? Do you have a dedicated insurance biller? Time this takes for an employee to be on top of?
Simple if the medical ins pays. I have no dedicated biller. This takes me less than 5 min per medical claim. Your vision claims may take longer if you have to enter in lens/frame info.

-What is a "Clearing House Fee", and what do they typically run?
If you are set up with VSP, you will have access to Eyefinity, which is a clearing house. They fee per claim, and it is a NOMINAL amount.

[Jubilee]

VSP supposedly will want the doctor to be a majority owner. There are supposedly a few ways to get around this, but be prepared in case you are denied. Though there are plenty of resources on how to make money filing VSP as an Out of Network provider.

Eyemed isn't as particular. Though they may not include you in ALL plans. They have 3, maybe 4 levels. One they have been claiming for years is being phased out, though I see some client groups still being switched to that plan.

Both of them have dedicated portals that are simple to navigate and fill out. The only downside (besides both wanting to use specific labs) is that VSP (eyefinity) comes back with a list of codes on a cms1500 like form. If you aren't familiar with all the codes, it can be frustrating to figure out what each code is...

To file medically, it will be different. Several of the medical plans have their own portals now that you can get eligibility and claims information.. even filing. Though it can be a pain to have to recall 5654681 sites and passwords. While eyefinity does have some basic clearing house capability, I really like Trizetto or Availity for this. Both have a basic system that is free for certain commercial entities, and have the ability to have increased capability for a fee. I pay Trizetto (aka Gateway EDI) between $80-90 a month to have unlimited filing, online claim correction, Electronic Remittance Advice, and so many eligibility inquiries per month. I find their site easy to use, intuitive, and I love the ease to track what is happening in the payment cycle. That being said.. while it can submit to Anthem, I can't find out what happens AFTER the claim is sent and accepted. This is where Availity comes in handy because they are the designated processor for Anthem. Anthem has a dedicated payer space on their site where I can send claims, check eligibility, and research claim history.. at no charge when I use them for Anthem or Humana..

Something to keep in mind with insurances is your pricing. Especially on the vision care plans. You will want to make sure your markups are enough you still are clearing money after receiving the reimbursements you get. Some vision plans will only pay you $40-50. You get wholesale back on the frame and a dispensing fee.. Lenses since they cover costs, the insurance company will CHARGE YOU for the lenses. Those costs may be MORE than what you have negotiated from your lab of choice. Its very easy, especially with when dealing with PALS for you to end up OWING the insurance company instead of receiving additional payment.

Keep in mind, you did collect funds from the patient..so its not like you didn't make anything.. but for some reason some offices are surprised when they realize they owe Eyemed $250.