Diabetes and Vision Ins. - Coordination of beneifts

[TECFayettevilleAR]

Hello all -

I am new here and in desperate search of help. :)

I would love to know how everyone handles Diabetic patients. Do you make them use Medical Insurance or do you coordinate benefits. Can you tell me your process...the most efficient is what I'm set out to find. Who pulls the auth if you are sending to medical and then coordinate benefits...front staff? billing staff?

How do you all handle refraction...going to medical then to vision...what's your total process there?

Thank you so much in advance for your help!

[jpways]

First, assuming that the medical insurance doesn't pay refraction, and from my personal experience about 60% of non-Medicare/Medicare Advantage plans pay refraction (and about 20% of Medicare Advantage plans and Medicare secondaries do as well), then you can look at vision insurances to pay it.

So assuming that the Medical plan does not pay the refraction, this is still a hard question to answer the short answer is it depends on the Vision Insurance company rules, and concerning coordination of benefits and refractive only exams.

To get to full answer refer to the provider manual for each plan and look for a sections that say Coordination of Benefits or Diabetic Exam.

So for an example let's look at VSP, if they have Diabetic Exam Program (Type 1 only) or Diabetic Exam Plus program (Type 1 and 2) then you submit to the medical insurance first and then anything that the medical insurance doesn't pay you can submit to VSP for reimbursement (Certain restrictions apply on diagnosis codes and procedures check the plan manual for complete rules). However, if they don't have one of these plan, you may still submit for Coordination of Benefits for the exam and refraction but you have to wait for the medical insurance has determined benefits, assuming the plan allows coordination of benefits. But you can't submit for just a refraction.

[Jubilee]

What they said :)

We handle it on a case by case basis. Usually we will try to bill the medical first. We do coordinate benefits as much as possible. Usually this makes the patient a bit happier as they sometimes will end up with no copay at all by the time the medical and vision work together. The vision care plans that don't allow for COB on all plans (such as Eyemed) we will work with the patient. Sometimes they are willing to pay for photos, etc out of pocket

[TECFayettevilleAR]

Thanks Jubille - so handling it on a case by case basis...does that mean you do it when the patient asks?

[TECFayettevilleAR]

Great information, thank you guys. We are trying to figure out the most efficient way to do this process.
Patient comes in for a diabetic exam or a Medical Exam w/a refraction. Say they don't even know they have this coordination of benefits option...
We aren't sure if we should have our check in staff pull the auth for Medical and Vision on every patient with Diabetes at check-in. Then there is the problem of knowing once the payment comes in from the Medical Insurance to know this patient has a vision diabetic plan to forward on the claim to. (as you know, not all vision plans have diabetic benefits). Then there is the refraction - I know about the coordination of benefits - the same question arises - do we mention this to every patient here for a medical exam that if there is a refraction and they have vision insurance we can bill their vision insurance for the refraction if the exam benefit is still available. Then once the payment comes in from the Medical we need something to trigger us that we have auth'd their vision insurance to pay the refraction. This is probably clear as mud...

[jpways]

does that mean you do it when the patient asks?

No, Diabetic exam is always medical, I don't believe that any vision insurance allows themselves to be the primary insurance for the exam when the patient is diabetic (or has glaucoma, AMD, or the myriad of other serious diseases that are primarily ophthalmic in nature or have ophthalmic manifestations, unless they require medically necessary contact lenses, though again the exam may still be medical but it depends on the vision plan's rules).

do we mention this to every patient here for a medical exam

It is advisable to do this

that if there is a refraction and they have vision insurance we can bill their vision insurance for the refraction if the exam benefit is still available

It is up to you, it comes back to whether you know if the medical insurance pays the refraction, if you consistently bill refraction to the medical insurance (which if you do refraction you should be whether you expect the insurance to pay it or not) you should be able to go back and see which insurance pay and which do not. One tip I can give you from personal experience when looking at Blue Shield look at the prefix not just the location, for example with Anthem even in plan that are just in Ohio I have some that pay and some that do not, but with all Highmark Plans (Western PA and WV) they always pay if it's not a Medicare Advantage plan. If you know this then you can set up a system that you can know if they have X Medical Insurance either know that you have to collect refraction at the time of exam or warn the patient that they may be billed.
And there is a third option (though it runs the risk of offending more patients than any other option that has been mentioned) unless you have a patient where you know that you an collect the refraction from their medical insurance or they have one of the plans that you can always billed refraction only exams (like Eyemed) always collect your refraction fee and write a refund when you end up collect refraction from another payor.

[David_Garza]

I don't believe that any vision insurance allows themselves to be the primary insurance for the exam when the patient is diabetic (or has glaucoma, AMD, or the myriad of other serious diseases that are primarily ophthalmic in nature or have ophthalmic manifestations, unless they require medically necessary contact lenses, though again the exam may still be medical but it depends on the vision plan's rules).

HaHa! Tell that to VSP and EyeMed

[fjpod]

There is a lot of confusion and differences of opinion on this subject. There is no single answer that I think anyone can give you.

Many (most) vision plans do not simply pay for a refraction. If you look at your contract, they probably cover a comprehensive eye exam, which in their small print, will sometimes even include a dilation if deemed necessary by the doctor, and it is a standard of care. And many medical plans DO cover an annual comprehensive eye exam, including refraction. You cannot bill both on the same day.

Which insurance company you bill, should be driven more by the complaints or symptoms a patient may have. If they come in and say they really are having no major problems, and just want to get new glasses, then you should bill their vision plan....AND, you may have to perform a dilation because it is the standard of care for diabetics, even if the plan doesn't necessarily pay extra for it. If a patient comes in and IS complaining about potentially more serious visual problems that can very well be related to diabetes, then it might be more important to perform and bill for a comprehensive exam under medical coverage.

Many times, it's just....up in the air. Sometimes, even I as a doctor, cannot get the patient to more clearly state....TELL ME WHY YOU ARE HERE! So don't expect your front desk to always be able to determine which company you are going to bill. This is why you are in such a quandry.

What I try to do is determine if the patient is hell-bent on getting new eyewear today, with no major visual symptoms. If they are, and I find no untoward exam findings, the patient will usually not want to be dilated because: a) they didn't plan for it, or b) it will interfere with their ability to select new eyewear. In these cases I will have the patient come back under medical for the DFE related to some finding. (Assuming.....they don't mind paying their medical plan copays and or deductibles). If they do mind, then I may simply do the DFE under their vision plan.

Some patients obviously present with more severe symptoms, and findings, and the visit is performed under medical, with little thought given to whether new eyewear is going to be needed. Sometimes the vision plan might be used on a follow-up visit when a more stable Rx is available.

So, in my opinion, anyway, there is no single rule you can apply at the front desk that will work in every case. It is really patient dependent and patient driven. You can see that you really need more of a flow chart to figure it out, but I have never been able to get that to work either.

[drk]

VSP has some diabetic eye care program that some stupid employers purchase. It's unnecessary, and any one who deals with VSP knows they are vicious and untrustworthy. Avoid that program like the plague.

The big problem as I see it, is that most optometric patients are vision care plan-oriented. That means, they show up expecting to use their "eye insurance", meaning "EyeMed" (aptly named to confuse) and "VSP" (who deliberately obfuscate their role as a vision care plan).

Now, you seem to work for an ophthalmology group, and that patient population is not the same. If they're sick, they're happy to use their health insurance. If they are well patients, they may know about their vision plan, if you indeed take that stuff. Different mindset.

In optometry, and with diabetes being about 20% of patients, it's not uncommon to be following them as refractive error (vision plan) patients and then they develop diabetes. Now you have to change to medical insurance, with high deductables and high copays for specialists? Hard sell. Very hard.

(Not to gripe, but anytime your glycosylated hemoglobin nears 6% PCPs freak out and put you on an oral hypoglycemic. A change in the criterion for diabetes is partly responsible for the epidemic as much as the fact that 1 out of 2 Americans are fatties.)

So the real question is when to pull the trigger? We don't bill the health plan to monitor hypertensives, normally, unless severe/retinopathy exists. What about "today's" diabetes?

[TECFayettevilleAR]

I guess what I am trying to ask is how your office has been able to efficiently streamline the process? Could I get an example of your workflow for your diabetic patients with these vision plans? I understand how the plans work, the coordination of benefits, what the patients assume, etc.

[TECFayettevilleAR]

We are an Optometrist/Ophthalmologist practice - that accepts vision insurance as well as medical

[drk]

The patients are ignorant, by and large. They "expect" to not pay anything, ever. So that's a non-starter.

The process is to submit the claim for the visit with the refraction to the medical payor. Then they will adjudicate the claim.

Of course they will leave copays, coinsurances, deductables, and non-covered services (refraction) as patient responsibilities. You cross over the claim to the vision care plan (manually, as the health insurers don't) and you get a cash allowance to defray those expenses.

EyeMed supposedly will pay you their entire exam allowance towards any balance due. Supposedly. Good luck with that. And you have to send a paper claim.

VSP allows electronic claims submissions for COB. See their manual for more information.

Seriously, though, it's a giant pain in the butt and the dollars are minimal. I'm not a fan, but we do it occasionally.

[TECFayettevilleAR]

Thanks for the information - It is a pain in the butt and we don't want to do it but we feel that we have too. We understand the steps it takes - we just wanted to know the most efficient way to work thru the process. We just wanted feedback on how other offices streamline the process.
FOR EXAMPLE (this is what I'm looking for in office workflow): Patient comes in for a medical exam; front staff checks them in and they verify the patients insurance (medical and vision); patient has a medical insurance that doesn't cover the refraction; they see that the patient has a vision benefit available; the front staff lets the patient know that if the doctor performs a refraction we can bill that refraction to the vision insurance, which will use their vision benefit for the period; the patient says...GREAT!......; how does your staff inform the billers that the patient is eligible and wants their refraction sent to their vision insurance AFTER the medical insurance pays....I understand that I send in the EOB from the medical insurance and wait for payment...etc...etc....How does the information efficiently get relayed to your billing staff when the front staff are the ones that determine if the patient would like this to happen or not.

[smallworld]

Wait until your billers have a medical claim that takes a year to process and its then too late to bill the vision plan for the refraction.

[fjpod]

If you're in a practice that provides both levels of care....it is tough, as we both have described. In my practice, we do a lot of both, and we have no OMD. There is an occasional patient that comes in and they know what they want/need, but for the most part, your doctor may have to decide during the exam. Your front desk should have both insurances up to date in the record. Your front desk should TRY to determine the patients intent(s)...but this may change. You should let your docs know if a referral is required for medical testing such as DFE or imaging.

[becc971]

Thanks for the information - It is a pain in the butt and we don't want to do it but we feel that we have too. We understand the steps it takes - we just wanted to know the most efficient way to work thru the process. We just wanted feedback on how other offices streamline the process.
FOR EXAMPLE (this is what I'm looking for in office workflow): Patient comes in for a medical exam; front staff checks them in and they verify the patients insurance (medical and vision); patient has a medical insurance that doesn't cover the refraction; they see that the patient has a vision benefit available; the front staff lets the patient know that if the doctor performs a refraction we can bill that refraction to the vision insurance, which will use their vision benefit for the period; the patient says...GREAT!......; how does your staff inform the billers that the patient is eligible and wants their refraction sent to their vision insurance AFTER the medical insurance pays....I understand that I send in the EOB from the medical insurance and wait for payment...etc...etc....How does the information efficiently get relayed to your billing staff when the front staff are the ones that determine if the patient would like this to happen or not.

Okay, so if i'm reading this correctly you are talking about coordinating benefits, so you would be billing out FIRST to the medical, and then to the Vision?

Our office typically bills out the diabetic exam itself to the Vision plan, and then bills out all testing to the medical insurance. There is a placeon VSP to check diabetic, I think Eyemed you can specify as well although I don't think the reimbursement is any better. I don't BELIEVE that you can bill simply a refraction to a vision plan, it has to be exam with refraction. as far as coordinating benefits I know it can be done with some plans, but I don't know how to make it happen. The way I explained in the first sentance is how both offices I have worked at have done it.

[David_Garza]

There is a placeon VSP to check diabetic, I think Eyemed you can specify as well although I don't think the reimbursement is any better.

There is no obligation to give this patient medical information to their vision benefit plans.

[Jubilee]

We will actually try to coordinate as much as possible. We consider it a win-win. The office usually gets higher reimbursements, and the patient will save as well. The times we don't are when a patient has a deductible, high co-insurance or a situation where we can see it will end up with the patient paying an exaggerate amount out of pocket. We will discuss with them how they prefer to proceed. If we need to do more indepth review than a "screening" can provide (iWellness OCT) or Retinal photos due to IDDM or other path, then we will discuss whether to bill or have patient pay out of pocket (with a small discount for payment in full on the same date of service)

[Jubilee]

You can coordinate benefits. This isn't simply billing the refraction to the vision care plan. Though some will allow that. This is having the vision care plan act as the secondary payer. I had a case where the patient had a $40 medical ins copay for their exam and no refraction coverage through it. Coordinating with VSP, I had the medical plan cover $70 towards exam, patient was to pay her $40 copay. VSP paid $13 for the refraction and the $40 copay portion of the exam. My total collected was $123 for something VSP would only pay me $60 for.

Everything was legal. Patient paid ZERO out of pocket, and VSP had a copy of the Remittance Advice with paper claim to process their portion.

As to workflow, if patient is a known to have potential medical issues (diabetic, medication toxicity, etc) then we pull both medical and vision. We let the doctor dictate the complexity of the exam based upon chief complaint and testing done.

from vsp:

Coordination of Benefits Between Health Plans and VSPPlans

Determining Primary Coverage

If the exam is medical, bill the health plan or Medicare as primary. If the exam is routine, bill VSP as primary unless the patient has routine coverage through their health plan.*

*Patients covered under the Federal Employees Dental and Vision Insurance Program may have routine coverage through their health plan. For more information, check the Federal Government Client Details in the Choice Network Manual.

Health Plan or Medicare as Primary Coverage

If the health plan covers the exam only, submit the exam claim to the health plan as primary and the materials claim to VSP as primary. Medical plans typically have higher copays than VSP and may have deductibles. They also don’t typically pay for refraction. To save money for your patient, coordinate benefits with VSP to cover the unpaid portion of the exam, if any, including the refraction.

Submitting the Claim

• * Coordinate benefits between the health plan and VSP for the exam/refraction. Tell your patient that coordinating benefits will exhaust their VSP exam benefit for the eligibility period, but will save them money.
  * Submit the claim to the health plan carrier for the exam and refraction. Be sure to include a refractive diagnosis for the refraction and the appropriate diagnosis for the exam, based on your professional opinion.
  * For us to consider payment, the CPT code(s) billed to the primary carrier must include an appropriate exam code plus a routine or refractive diagnosis code for the refraction. Indication of post-cataract (presence of intraocular lens - see diagnosis code below) will preempt the requirement for a routine or refractive diagnosis code for clients that offer a post-cataract material benefit to their members through VSP.
  * For dates of service on and after 10/1/15, diagnosis code Z96.1.
  * For dates of service on and before 9/30/15, diagnosis code of V43.1
  * We’ll pay up to the secondary exam allowance, but not more than the patient’s out-of-pocket expense.

For Paper Claims

• * When you receive payment from the health plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

For Electronic Claims

• * When you receive payment from the health plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

Follow these instructions:

• * Provide the same diagnosis, exam, and refraction codes from primary claim
  * Select Yes (box 11d) there is another health benefit plan for eyecare. This will open a new section. Be sure to leave the field for Secondary Authorization Number blank
  * Skip the Additional Information Detail section (boxes 10, 15 – 18, 22 & 23). This section isn’t needed.
  * Complete the Other Insured section as below:

• • *	Enter “Same” in box 9
    *	Enter “NA” in box 9a
    *	Enter primary health plan in box 9d

• * Click “Calculate and Continue” at the top left
  * List amount paid by primary carrier(s) in box 29
  * Enter this exact language in box 19: “secondary COB claim patient resp $XX.XX” (Indicate the dollar amount of the patient’s responsibility in place of the XX.XX)
  
  
  There is a calculator for COB under the VSPOnline tab.