Optometric Billing Solutions does insurance billing for optometrists in over 40 states, so we are very familiar with insurance payers in all parts of the country.  Because we deal with so many different payers, we’re accustomed to dealing with the occasional quirkiness that just comes with the territory.  It seems nearly every state has at least one carrier with a weird rule that’s outside of industry norms.  However, while an occasional commercial plan may have some random weirdness, a lot of state Medicaids have unusually demanding filing requirements that can make claim payment difficult if you don’t know how to traverse the red tape.

Not long ago, a large group our billers were in the break room when the subject of Medicaid came up, and many had horror stories about the lengths they have to go through to get their Medicaid claims to pay.  Common problems were rules outside of normal billing standards, short timely filings, website with antiquated software, difficulty getting representatives on the phone, long wait times, time-consuming forms to fill out for corrected claims, Medicare crossovers not working, and long wait times for payment–just to name a few.

However, if your practice has a Medicaid AR that is out of control, we have good news!  Regardless of how many rules your Medicaid payer has, our billers know how to get your Medicaid claims to pay.  We are experts at tracking down filing requirements, reading provider manuals, calling reps, and following procedures for even the most demanding Medicaids.  If you need help with your Medicaid claims, we invite you to call us.  We can help!

Medical insurances usually don’t cover contacts unless they are considered medically necessary–and even then, many don’t cover at all.  Contact lenses are defined as medically necessary when the patient has an eye disease or prescription that has to be managed with contacts  because glasses can’t provide sufficient correction. Examples of diagnoses that may qualify for medically necessary contact lenses are keratoconus, aphakia, post-corneal transplant, corneal dystrophies, ametropia, and anisometropia.

Many commercial medical carriers don’t cover medically necessary contacts.  If they do, you have to be careful about reimbursements on a commercial fee schedule. Sometimes insurance reimbursements are not enough to cover the office’s cost on specialty lenses because the newer technology is so expensive. Therefore, it is critical to call the patient’s insurance and verify benefits prior to ordering or dispensing contacts.  When checking benefit information, always get a dollar amount, not just coverage as a percentage of their allowance.  (For example, 80% can mean 80% of $150 or 80% of $1,200. You have to know!)  Ensure the insurance allowance is enough to cover your costs because you cannot charge your patient any overage.

Also, with commercial carriers you can file a claim for each office visit during the fitting process.   Routine vision carriers treat 92310 as a global fee; however, per CPT coding guidelines 92310 is not actually a global code.  Therefore, each time the patient comes into the office, create a claim with a per-visit fee when filing to commercial carriers.   NOTE:  If the patient’s diagnosis is keratoconus, some commercial companies require that the initial visit be filed with 92072. Follow up visits can then be billed with 92310 or some doctors use a lower level E&M code.

Please note that the rules for filing with routine payers like VSP or EyeMed are different and very clearly defined.  However, if you anticipate filing an insurance claim to a medical carrier, you’ve got to know the patient’s benefit before you start the process.  In order to help, we have attached a predetermination form your practice can use when verify benefit information with commercial carriers.  Just click on the link below!

Med Nec CL Predet for Commercial Ins