Turning Problems into Profits

Training Videos are Working

The office training videos are back up! You should be able to log in now; the password is the same,  Thank you for your patience!

For our offices who haven’t looked at these videos, we invite you to check them out!  Click on Office Training on the upper right menu bar. We created the content because we found that staff members at our offices often had the same questions, especially when they hired new staff. So these videos are meant to train your staff about the insurance side of their positions. Each video runs from 5-10 minutes in length. All videos are password protected, so if you don’t have the password, please call your coordinator or Mary at 877-727-3695, ext 210.


EyeMed Issuing Corrected 1099s

3.1.18  EyeMed is currently notifying providers that some of the 1099s they issued had wrong payment amounts, so they are currently in the process of reissuing corrected 1099s.  Per EyeMed, clinics should be getting new 1099s within the next two weeks.   The corrected form will have an X at the top in the CORRECTED box, and this is the one offices must file with their 2017 returns.


1.22.2018  The latest iteration of inaccurate EyeMed disbursements involves remits from the middle of February for which the paid amount is exactly double what the claims on the EOB add up to.  For example, the remit may say the deposit was for $350, but there will only be $175 in payment when we post.  Other clinics are seeing two identical remits for the same amount, same patients but with different check numbers.

EyeMed claim representatives tell us they’re aware of the problem but they have little additional information.  As we encounter these double payments, we’ll be reaching out to our offices on the Team Site to have you confirm how much money was actually deposited into your bank account.  If you were truly paid double, we’ll need to post the additional monies so we’ll have something to offset future chargebacks when EyeMed recoups the overpayment.   But it could be that you were paid correctly and it’s just the remit that’s wrong.  Either way, we have to know for sure in order to reconcile accounts correctly.

Notice to our OfficeMate Clinics

1.30.18  ATTENTION OBS OFFICEMATE CLINICS:  Please do not update to Version 14 in OfficeMate without talking to OBS first! This was a major upgrade that switched the program from a Visual Basic platform to a .NET platform, and there are TONS of ISSUES.  We are seeing lots of problems with our clinics who already upgraded, and you don’t want these headaches!

TRICARE East: No updates yet on how claims are paying.

TRICARE EAST:  We have no updates yet about how TRICARE East claims are paying. You’ll remember we’re looking to see if doctors are paid more if they’re credentialed directly through TRICARE vs doctors credentialed through the EyeMed TRICARE network. Unfortunately, the new East region is getting off to a slow start. They’re quoting a 30-90 day processing time for electronic claims submissions, so it may be a bit before we have our answer. But we will keep you updated just as soon as the first claims come back for doctors in each credentialing group!

EyeMed No Longer Coordinates Medical Exams


EyeMed has changed their medical coordination policy for refractions.  Many medical payers do not cover refractions because they are routine in nature, but EyeMed has always paid for these refractions under the patient’s routine exam benefit when medical claims were coordinated. This changed in November; EyeMed no longer covers refraction-only COBs.  When we questioned EyeMed representatives about this change, we received a variety of answers, from refractions are content of service to an exam (which, of course, is not correct according to the CPT manual) to EyeMed wants to ensure patients get comprehensive examinations (which their medical EOBs clearly show they did).  A few weeks ago we talked to a senior official at EyeMed and were told that, except for a handful of plans, EyeMed contracts do not cover coordinations, and they were just trying to get claims processing back in line with their contracts.

Whatever the reason, this policy change denies many EyeMed patients access to their exam benefit.  For patients with medical conditions or eye diseases, the refraction is the only routine professional service they will receive during the year. EyeMed patients must now pay for the routine portion of their exams even though they have routine coverage.  At the very least, this policy financially penalizes patients and, at the very worst, has the potential of interfering with appropriate patient care if patients elect not to proceed with a medical exam because of the financial barriers EyeMed has imposed.

OBS currently have unpaid refractions sitting on patients’ accounts from COBs which EyeMed denied. We confirmed with EyeMed that these are patient responsibility and not a contractual write off, so we will be transferring these balances to patients with a note that EyeMed denied their claims.  Moving forward, you will need to collect the refraction from your EyeMed patients if their exam is medical. If you encounter unhappy patients, offer to give them EyeMed’s number.  The EyeMed official we spoke with did say that the company may consider revising this policy in the future, and he welcomed calls from offices and patients who had concerns.

This process only affects EyeMed patients, not VSP.  VSP has always placed a high value on customer service, and they automatically allow coordinations except for a few plans which specify otherwise. (If it helps you remember, think of it as an inverse ratio:  EyeMed only has a few plans we can coordinate, but VSP only has a few plans for which we cannot.)  VSP pays up to $66 under coordination, less the patient’s copay.  It is only EyeMed patients for whom you will have to collect the refraction at time of service.

If you have questions or concerns about EyeMed’s no-coordination policy, do not hesitate to call your coordinator–and EyeMed!

Health Net Federal Services is new TRICARE West contractor

1.10.18  With so much confusion centering on Tricare East, it’s worth remembering that Tricare West also had an important change–not a new region, but a new contractor. Their MCS contractor has moved from UHC Military to Health Net Federal Services. West region providers who are not already contracted with Health Net Federal Services (HNFS) may need to fill out a new Tricare West enrollment packet.  However, doctors may still choose to see Tricare patients as a non-network provider, but Prime patients will need a referral or prior auth to go to a non-networking provider for care.  You’ll also want to register for the secure provider portal where you can look up eligibility, submit authorizations, and check claim status.

Below are some helpful links to get you started!

Claims for dates of services on or before December 31, 2017 should still be submitted to UnitedHealthcare Military.  In addition, myTRICARE.com will continue to be available for account information and claims submission through April 30, 2018.  However, all claims for dates of service on or after January 1, 2018 must be filed to Health Net Federal Services, but HNFS will honor all active referrals and authorizations issued by UHC Military prior to January 1.


Tricare West Region:  Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (except the Rock Island Arsenal area), Kansas, Minnesota, Missouri (except the St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (areas of Western Texas only), Utah, Washington, and Wyoming.

Things to Know in January: Duplicate Superior Payments and Medicare Deductibles

1.8.18  SUPERIOR VISION PAYMENT ISSUES: Some of our clinics recently received duplicate payments from Superior that were previously issued in September. When we called Superior we were told that their new payment system did not successfully issue the original EFT payments, which is why they are now being reissued with interest. However, we are also finding that some of our offices that get paper checks have received duplicate payments as well, so it appears Superior is reissuing ALL payments from that time frame. Some offices who get paper checks are truly receiving double payments that will have to be recouped. If you are an OBS clinic, please call your coordinator if you have questions!


1.2.18   2018 MEDICARE REMINDERS:  The Medicare Part B annual deductible will be $183 in 2018, the same as last year. As you start to see Medicare patients in 2018, you can check how much of their deductible has been met on most Medicare websites or IVR. Clearinghouses like Trizetto also offer this service, and you can often sign up to get this information on Availity. Secondary Medigap B, C, and F policies usually pick up the Medicare’s deductible, but collect the noncovered refraction!  Also, remember to always check seniors’ insurance cards at the beginning of the year since they may have changed to a Medicare Advantage plan. And finally, remember that Medicare patients will get new cards and ID numbers beginning in April. It will be critical for your staff to scan the new cards and update the new numbers in your software!

Tricare East Just Got More Confusing!

12/30/2017 (Updated 1/3/17).  With less than 48 hours before Tricare North and South transition into the new East region, it now appears that everything we thought we knew about this change may have been wrong.  Why?  Because last minute information coming from new Tricare East Provider Relations Representatives is contradicting what EyeMed has been saying. The only thing that is clear at this point is the principal players aren’t giving out the same reports.

EyeMed has been contacting optometrists in the eastern half of the US over the last six months telling them that they had to sign a new contract with EyeMed in order remain a Tricare provider after January 1, 2018.  According to EyeMed, doctors’ contracts with Tricare North and South would end on December 31, and Humana Military, who was awarded the contract for the new East region, had selected EyeMed to administer all vision claims. Providers also learned that their reimbursement would be reduced to 70% of CHAMPUS allowables.  In fact, this is still the information being given out by EyeMed’s provider relations department if you called this week.

When EyeMed started emailing new contracts to doctors, Tricare North and South didn’t have a lot of information available for providers either since their regions were being phased out.  However, by December the East region was taking shape and provider relations representatives were being assigned.  Because there were so many unanswered questions, Branda starting making calls to Tricare to try to get clarification about such things as out-of-network benefits.  She had long hold times and several transfers, but the real surprise came when Tricare East representatives informed her that nothing in our doctors’ contracts had changed.  If they were Tricare providers for North or South, they would remain Tricare providers for the new East Region. They didn’t have to do anything differently or execute new contracts. To confirm this information, a Tricare representative directed Branda to Tricare East’s website where she could look up contracting providers. A quick search revealed that many of our Tricare doctors who had not signed the EyeMed contract were still listed as Tricare providers in the East Region beginning January 1.

Faced with such opposing information, on Thursday Branda placed a call directly to Dr. Joe Wende, Senior Director of Medical Services at EyeMed.  When Branda reported to Dr. Wende that she had been told by Tricare East, Dr. Wende had no explanation for the contradictory information.  According to Dr. Wende, Humana Military had contracted with EyeMed to use their provider network, and based upon what they had been told by Tricare he was still under the belief that if doctors were not contracted with EyeMed’s Tricare network they would no longer be Tricare providers.   Of course, rather than getting clarification, this conversation left us in an even greater quandry about what to believe and how to advise our clinics.

Today, one of our Virginia doctors forwarded us a letter from their newly appointed Tricare East provider relations representative.  Here is a direct quote:  “The request you have received from EyeMed is not mandatory.  You have no requirement to opt into that agreement.  If you have opted to sign their contract you have to abide by the new contract.  If you opted not to contract with EyeMed it will not change your current agreement with us.  It will remain the same.”

At this point, we can’t be absolutely certain of anything since the information still coming from EyeMed and Tricare East is totally different. There are still many unanswered questions, the most important being these:  Did providers already credentialed with Tricare sign an unnecessary contract with EyeMed agreeing to take a reduced fee, and will doctors who are still contracted directly with Tricare be paid 100% of CHAMPUS allowables, while doctors who signed the EyeMed contract get 70%?  We don’t know the answers to these questions yet, but we will.

The only way to know for certain how claims will process is to file them and track what happens.  We will keep you updated as soon as the first claims start coming back.  In the meantime, we would advise doctors to do nothing more until we have better information.  If you are an OBS practice, be looking for emails from us with updates.  If you are an optometrist just trying to figure out what is your best course of action, continue to monitor our website.


Updated 1/3/17.  The Humana Military website we originally listed to look up provider credentialing status has moved to a new location.  Please select East Locator.  https://www.humanamilitary.com/find-a-provider

If you are not listed on the website, continue to check back.  Humana Military was still updating their provider list as late as this morning.

Upcoming Deadlines and Changes our Offices Need to Know About


AVOID A 4% MEDICARE PENALTY IN 2019! The Centers for Medicare & Medicaid Services’ (CMS’) new Merit-based Incentive Payment System (MIPS) reporting year began Jan. 1, 2017.  In order for doctors to avoid penalties for failure to report, they must take steps before December 31.

Doctors who do not report in 2017 and are not exempt will be assessed a 4% penalty on their Medicare reimbursements in 2019.  However, this can be avoided but reporting ANY data this year. You can avoid the penalty by reporting just one Clinical Practice Improvement Activity or one Quality Measure for one patient you see before December 31, 2017.   For more information, visit the AOA website.  Besides the AOA, CMS and your practice management software vendor are other good resources.



Tricare is changing their enrollment period from a fiscal year that used to reset on October 1 to a calendar year, beginning January 1, 2018. This means that your Tricare patients’ deductibles will now start over again each January rather than October. For more information, please visit the Tricare website:  https://tricare.mil/CoveredServices/BenefitUpdates/Archives/10_12_17_Changes_FY2CY

IMPORTANT UPDATE ON TRICARE EAST:  Last minute information is looking like EyeMed or Tricare may have given optometrists in the new Tricare East region incorrect information and that doctors do not have to be part of EyeMed’s network to be Tricare providers. If this is true, thousands of doctors signed unnecessary contracts to take reduced fees! Go to https://optometricbilling.com/tricare-eyemed


New Medicare cards with new patient ID numbers are coming next year.  Be ready!  In order to prevent identity theft, Medicare will stop using patients’ social security numbers as part of their ID starting in 2018.  Instead, all Medicare patients will be issued a new Medicare beneficiary identifier (MBI), and Medicare will start mailing out new cards with the new number in April of 2018.   This means that starting next April, our offices should start asking Medicare enrollees for a copy of their new card and begin updating their software with the new ID numbers.  Medicare plans to honor both ID numbers on claims until the end of 2019, after which they will only accept claims with the new MBIs.  Please go to the CMS website for more information for providers about this upcoming change.

Go to https://www.cms.gov/Medicare/New-Medicare-Card/index.html.



UPDATE: The merger was ratified on December 1, so officially both Davis and Superior are now combined under the same Centerbridge/Highmark corporate umbrella.  However, we talked to a company representative and learned that for now both companies will continue to operate independently with “business as usual.”  Therefore, providers can expect no immediate change with the completion of the sale.  While the company emphasized there was currently no official date for any changes, they did concede that these would be coming at some point in the future and advised us that offices should be looking for a fax which would outline these changes when that time comes.  

Have you heard that Davis and Superior are merging? Centerbridge Partners, owned by Highmark, who already owned Superior, is in the process of purchasing Davis Vision and plans to merge the two companies. Reports indicate that the sale should be final somewhere near the end of the year. It’s too early to know what this will mean to providers, but look for more information in the months to come.


Many practices use Facebook as a great tool to stay connected with their patients.  However, coming up with informative posts and interesting graphics is always a challenge, so OBS decided to help!   We got creative and made dozens of royalty-free marketing, inspirational, educational and holiday graphics for you to use on your Facebook page!  The images can be used alone or in conjunction with your own content.  This was so much fun, we’ll do it again, so bookmark the page to check back later. Click on the picture below to preview and download images.  Enjoy!

Coding and Billing: Medical-Routine Coordination of Benefits

In order for today’s optometric practices to thrive financially, they have to move beyond the world of routine vision insurance.  It is difficult to cover chair costs and keep your doors open on $45-$70 reimbursements from routine carriers. But far too many optometrists are regularly accepting these lower reimbursements simply because they do not understand their coding and billing options.

The purpose of this article is to explain billing protocols that allow optometrists to collect fairer reimbursements for their time, decision making, risk, and expertise.  In short, it’s a crash course in coding and billing that has the power to help you and your practice increase insurance reimbursements if you are not currently following these guidelines.  ­­

A large part of the coding and billing confusion arises from the fact that optometrists live in a dual world of medical and vision insurances that few other healthcare professionals encounter.  Not understanding how to deal with this duality of payers, too many optometrists have taken the path of least resistance and file the majority of their annual exams to routine insurances, thereby losing thousands of dollars in lost income if they have provided medical care.

But optometric insurance billing does not have to be an “either-or” proposition.  Instead, ODs need to take a “both-and” approach through the process of coordination of benefits.  Optometrists have a unique opportunity with two types of insurances available for billing and, when appropriate, should move forward in filing claims to both insurances to significantly increase practice revenues.

Here is the basis for a successful insurance billing strategy which allows you to maximize your insurance reimbursements while minimizing your patients’ financial responsibility:  When providing medical care, bill patients’ medical health insurance first for a higher reimbursement.  After the medical payer processes the claim, coordinate any remaining patient balances to their routine insurance for additional payment.  It’s really that simple.

Considering that routine vision payers reimburse between $45 – 70 dollars for an exam and medical payers somewhere between $120 – $180­­, you will collect two to three times more from medical health insurances.  Not only are medical-routine coordinations a huge boon to the practice, but coordinations are meant to reduce patients’ out-of-pocket expenses as well, so in most cases coordinations are equally beneficial for patients.

However, based on your current office procedures, there may be some challenges that doctors will have to face when moving to a medical-routine coordination model.


BARRIERS TO A MEDICAL BILLING MODEL.  Let’s start by examining the main reason practices bill routine vision payers in the first place: It’s simply easier.  Medical billing requires a wider breadth of diagnosis codes, modifiers, and specialized filing rules.  Medical exams require greater chart documentation, time, risk, and expertise.  Medical insurances differ greatly from policy to policy, so understanding patient’s benefits is not as straightforward as routine insurance.  And finally, medical billing requires greater communication with patients.   Over the years we have found offices who are not up to the challenge.  But for doctors willing to put in the effort to overcome the barriers to medical billing, their reward will be a much larger bottom line and a more financially sound practice with monies available to reinvest in their business and their own futures.

What are the barriers optometrists face when implementing a medical-routine billing strategy?  The answer varies from doctor to doctor, but today we will discuss two of the most common obstacles and explore resolutions for both.  (We have made the assumption that you are already contracted with the medical payers in your area.  If you are not, then credentialing moves to the top of your list because unless you’re a network provider, you generally can’t file medical claims.)


Let’s start by clearing up two misconceptions:

  1. An annual exam does not mean it’s automatically a routine exam.
  2. Just because patients have routine vision insurance does not obligate you to file it as primary.

We’re not sure what doctors have been taught at optometric school or if there is someone on the speaking circuit giving erroneous information, but we find doctors adhering to these two beliefs religiously as if they were canonical law.  They are not.

However, doctors seeking clarification on medical vs routine billing might be surprised to find a very good resource in the largest routine vision payer in the industry, Vision Service Plan.  Per VSP’s provider manual, how you bill the exam is driven by the patient’s chief complaint. The chief complaint should be the primary diagnosis on the claim, and this determines whether you bill routine or medical.  If patients present with no medical complaints or symptoms and have no risk factors or eye diseases that need to be addressed during this visit and your care is primarily refractive in nature, then these exams are routine.  On the other hand, if patients present with medical symptoms or have a history of risk factors or diseases that must be monitored and evaluated, then these exams are clearly medical in nature.

The bottom line is this:  The patient’s chief complaint drives the reason for the visit. To bill patients’ medical insurance as primary, the chief complaint must be medical and reflected in the primary diagnosis in the first position in the exam. The patient’s medical conditions, symptoms, or risk factors should be recorded in the presenting reasons for the visit in the record, and you should perform and document objective testing as well as your treatment plan. Solid chart documentation is critical when billing medical exams, and doctors should follow the standard SOAP format in charting.

Here’s another important consideration:  Some patients’ medical insurances cover an annual routine eye examination.  In these cases, VSP guidelines say to bill the patient’s medical payer first and then coordinate with their routine plan. This allows you to capture the higher reimbursement from medical carriers, even for routine exams.  Check with the medical payers in your area to see which ones offer coverage for an annual routine office visit.

VSP summarizes their policy in one easy sentence:  If the patient has no medical chief complaint and the medical plan does not cover routine/annual exams, bill VSP.  Otherwise, bill the medical payer.  Other routine payers do not have VSP’s extensive policy manual, and many don’t address medical billing at all, inferring they’re leaving billing decisions up to the physician.  But since most doctors are VSP providers and VSP is the largest routine payer in the country, their fair and helpful guidelines can serve as a good rule of thumb when deciding how to handle medical versus routine office visits at your practice.


If your office has been in the habit of filing most annual exams to patients’ routine insurance, then patient education will become a critical factor in allowing a medical billing model to succeed.  Medical billing with coordinations will be a change for your patients, and you and your staff will need to spend the time to help patients understand the process.  Coordination of benefits is meant to reduce patients’ out-of-pocket expenses, so it will have a positive impact for most of your patients. Routine insurances usually pay for the refraction that most medical payers don’t cover, and some will even pick up the patient’s medical copay up to a certain limit.  In fact, it is not uncommon for patients to owe little (usually their routine copay) or nothing when claims are coordinated.

The exception, however, is patients who have high deductibles on their medical plans.  In these cases, the patient may want to have their office visit billed to their routine payer if their deductible is not met.  These patients can be confused or even upset that you’re billing their medical insurance, especially if you have not done a good job communicating with them throughout their visit.

In fact, patient education is so important in the medical billing model that OBS has developed two training videos for our clients to help them with this critical component of patient care.   If you are an OBS client, please reference our office training videos on our website called “Medical vs Routine: Increase Practice Revenue through Coordinations of Benefits.” (Click on the image at right.) In these videos we explain the finer points of patient education for both doctors and staff, discuss communication strategies, and offer sample scripting to ensure patients are not surprised at checkout to learn the claim will be filed to their medical payer first.

That being said, patients have the right to dictate their care.   In cases where patients with medical conditions wish to have their exam filed to VSP, your staff can explain that VSP will not pay for the medical portion of their office visit and offer them two options:  1) File to their medical plan first and then coordinate with their vision insurance the routine portion of their care or 2) have them return later in the week for a second visit to complete a medical follow-up. Regardless of their choice, patient education by the doctor and support staff is critical to ensuring medical billing goes smoothly.


FILING SECONDARY CLAIMS.  After the medical payer processes the claim, you can file the claim to the routine carrier for them to consider payment on any remaining patient balances. Your biller should know the coordination rules for each routine insurance since the method and manner of filing secondary claims varies by payer. (At the time of this writing, EyeMed appears to be eliminating their medical coordinations altogether.) In all cases, however, the patient’s routine benefit must still be available, coordinations will exhaust their exam eligibility, and only exams that include a refraction can be coordinated. There are other considerations your biller will need to know, such as how to handle write-offs when the routine payer processes the exam and under what circumstances the patient will still owe any outstanding balances. If your biller has little experience in coordinating claims, then she will need to spend time reading provider manuals and making calls to insurance representatives until she is well versed in the process.


FINAL THOUGHT:  If your staff is so busy that­ there is any question that appropriate follow up on claims will happen or that coordinations may not get filed, this might be the time to consider outsourcing your billing to experts who can help you through the process.   If you have been billing most of your annual exams to routine insurances or have never coordinated claims, then outsourcing can more than pay for itself.  In addition, you get to eliminate the expense of in-house billing and will often see increased revenues when your claims are being handled by dedicated professionals with the time, experience, and expertise to collect every insurance dollar due to your practice.


For a printable PDF of this article, click here.