Billing- Glasses for Medical Necessity

[kdw613]

Hello,

Anyone have any thoughts/ideas on how to bill Glasses that are "Medically Necessary" and get paid? We have a patient who developed (through a medical condition) photophobia. They received glasses less than a year ago. The Dr. updated the Rx and prescribed a tint to help alleviate the condition. The Insurance company said they might cover glasses as a Medical Necessity (they would not be eligible otherwise). I have the diagnosis code, what supporting documentation or other items should I send to substantiate the claim?

Thanks

[Hayde]

Hey, kdw!

Unless someone out there knows something I don't and can tell me I'm wrong, the patient's insurance company probably doesn't even know yet. First they get an authorization agent assigned who will decide how to interpret their criteria for 'medical necessity' that is obstinate up the point of inviting losing litigation. Then that agent will ask for documentation from patient's chart from the diagnosing physician.

Since the doctor's office doesn't get paid any more for that kind of effort, I wouldn't gamble my own reimbursement assuming they'll get to it in the time frame the insurance company wants it. Best to have the patient pay out of pocket and contend with the reimbursement themselves.

If that ship has already sailed and you're on the hook, you have to get in touch with the insurance for their specific criteria (in writing so it's less convenient for them to change their minds later.) Then you can charm up the patient's doctor's office to help you out with the encounter notes needed to check boxes.

I hope you can dodge it and put the onus on the patient, but if not I wish you the very best of luck!

[kdw613]

I was able to bill and get paid from the insurance company! I spoke with the MD and got a proper diagnosis, to go with the Therapeutic lenses.

It appears that the other 2 I billed are going through as well!

So far... So good!

Hey, kdw!

Unless someone out there knows something I don't and can tell me I'm wrong, the patient's insurance company probably doesn't even know yet. First they get an authorization agent assigned who will decide how to interpret their criteria for 'medical necessity' that is obstinate up the point of inviting losing litigation. Then that agent will ask for documentation from patient's chart from the diagnosing physician.

Since the doctor's office doesn't get paid any more for that kind of effort, I wouldn't gamble my own reimbursement assuming they'll get to it in the time frame the insurance company wants it. Best to have the patient pay out of pocket and contend with the reimbursement themselves.

If that ship has already sailed and you're on the hook, you have to get in touch with the insurance for their specific criteria (in writing so it's less convenient for them to change their minds later.) Then you can charm up the patient's doctor's office to help you out with the encounter notes needed to check boxes.

I hope you can dodge it and put the onus on the patient, but if not I wish you the very best of luck!

[NAICITPO]

I was able to bill and get paid from the insurance company! I spoke with the MD and got a proper diagnosis, to go with the Therapeutic lenses.

It appears that the other 2 I billed are going through as well!

So far... So good!

WOW!

What diagnosis code was used and what insurance company was it out of curiosity?

[kdw613]

I billed Buckeye (Ohio Medicaid Managed Plan) using code
G43.0 for Migraines. I verified the diagnosis with the PCP and fit Avulux lenses. I billed the insurance company as "Medically Necessary" and it was approved and paid.


QUOTE=NAICITPO;572080]WOW!

What diagnosis code was used and what insurance company was it out of curiosity?[/QUOTE]

[iD]

was there a certain requirement that needed to be met(rx wise) or did the doctor say it was for photophobia?

[NAICITPO]

Nice work KDW, will definitely keep this in our back pocket for the future.

[carlinataylor]

depends on Insurance.

[kdw613]

No Rx requirement and this insurance did not need prior authorization. I read the contract and found this out. In this particular insurance, "Medically Necessary" also covers Poly for Amblyopia and Orbital fractures.

QlUOTE=iD;572098]was there a certain requirement that needed to be met(rx wise) or did the doctor say it was for photophobia?[/QUOTE]

[kdw613]

Yes! My suggestion is to read the contract. I found that 2 of them do not need prior authorization. I adapted an insurances "Standard Written Order of Medical Necessity" to provide documentation and to satisfy prior authorization for a few.