3/30/14   The deadline is here for the new CMS 1500 02/12 HCFA forms in preparation for the nation’s move to ICD-10s.  By April 1, practices that file any paper claims must have upgraded their software with the new insurance templates.  The new form will have slots for 12 diagnosis codes rather than four, and codes will be sequentially noted by alphabetic pointers rather than numeric.  Among other changes, patient’s marital and employment/student status (box 8) and balance due (box 30) have been eliminated on the forms since these are not reported on 837P electronic claims.

If you have not done so already, talk to your practice management software vendor about upgrades to your system since payers will no longer accept the old 08/05 forms after April 1.  As of this writing, however, some optometric softwares are having to make last minute adjustments to meet the deadline.  OfficeMate had to pull their 11.1 version the week prior to the deadline, and Revolution EHR had to delay their scheduled upgrade. The MaximEyes’s upgrade has the required new format but as of right now, billers have to physically change number pointers to the corresponding letters.  If you have questions about the new HCFA format, contact your vendor for additional information.

The change to the new HCFA format only affects paper claims, at least until October (either 2014 or 2015, depending if the bill that passed the House this week and is on it’s way to the Senate is ratified).  We contacted four major clearinghouses– TriZetto/Gateway, OptumInsight/ENS, Emdeon, and Apex– and confirmed that even if you haven’t upgraded your software by April 1, your electronic claims will still process.  However, practices that use Print Image files to submit their e-claims rather than ANSI files will have to contact their clearinghouses to have their files remapped after they upgrade their systems.

ICD-10 changes promise to make life interesting for all of us in the industry!  It’s critical that practices regularly check their clearinghouse rejections and stay on top of their AR reports to ensure claims are going through and getting paid.  We expect ICD-10 to be even more problematic than 5010 was two years ago, and doctors would be wise to lay back a cash reserve to help carry them through the transition if we see similar issues that delayed transmission and processing of claims.  Every vendor, clearinghouse, and payer in the country will face the unique challenges that such a massive overhaul as ICD-10 will bring.  However, Optometric Billing Solutions weathered 5010 very well because we had the processes in place to ensure every claim got paid as quickly as possible.  Because they had us as a safety buffer, most of our practices were not even aware of the turmoil that affected their colleagues, and we are already planning to make ICD-10 go as smoothly!

4/2/14 Addenda:  The Senate passed the bill that included the delay of implementation of ICD-10 codes until  October 1, 2015, and last night President Obama signed the bill into law.  Certainly there are pros and cons to this delay, but on the plus side it will give practices additional time to prepare for the transition.  The new 02/12 HCFA forms, however, were not affected by the bill, and your practice is still required to upgrade your software to submit paper claims on the new forms.

1/1/2014  Beginning Jan 1, 2014, Superior Vision will offer plans that cover “standard” progressive lenses.  New and renewing groups will be offered this benefit, and in 2014 you may see many current policies transitioning over to covered progressives.

How Covered Standard Progressives Work.

• Your office decides what progressives lens you consider “standard.”  Superior does not define standard progressives by manufacturer, brand, or product.
• Each practice must offer at least one standard progressive lens,  and you set the retail fee. Whatever fee you set becomes your Superior patients’ allowance on all progressive lenses.
• Helpful Hint:  Whatever standard progressive lens you decide upon, it should probably be the least expensive progressive you can buy since Superior will only reimburse you $90, and you can’t charge the patient the balance on standard progressive lenses. (You can charge patients the overage if they purchase premium progressives.)
• The patient owes nothing on standard progressives.  For patients with these new plans, standard progressive lenses are covered in full with the member paying only the materials copay, if applicable.
• If patients choose a premium progressive, the member receives an allowance equal to the standard progressives retail fee you set.  The patient then pays the overage, less the 20% discount most private practices’ contracts require.

Take Away

The secret here will be up-selling  to premium progressives.  On standard progressive lenses, Superior will reimburse you $90 and you can’t charge the patient more than this.  However, on premium upgrades the patient will owe anything above the retail fee you set.

Please remember—

Current policies that just cover a base SV, BF, or TF lens are still in effect for the majority of your Superior plans.  For these plans, there is no change in Superior’s benefit structure; you will continue to be paid the same way.  However, you may see more policies move to the new progressive option as re-enrollments come up and policies are upgraded to include standard progressives.

7/31/13.  As many of you are aware, EyeMed just completed a beta test for moving their glasses over to a lab-based model similar to VSP.  In the near future, all EyeMed glasses will have to be made at an EyeMed lab.  The beta test started last spring with 150 clinics nationwide, three of them our clients.  In June, EyeMed reported the beta test was successful and announced their intent to adopt the model for all EyeMed providers, the transition to be completed by the end of 2013.

Indeed, EyeMed is moving forward.  Some of our clients will be moving to the new model next week.  We called EyeMed for more information on when other offices can expect to be moved and learned that clinics are being assigned a move date based on their tax ID.  One month prior to their expected move, EyeMed is contacting doctors through both email and letter, hopefully enough time to give offices the opportunity to review their new contract, sign up with a new lab, train on the new ordering software, and time to learn more about what lens manufacturers and products they will be able to use.  The beta test started with Essilor labs, but EyeMed recently announced that they were adding Walman Optical and the Luxottica Lab based in Dallas.   Providers will still provide patient frames.

We’re hearing some common concerns from doctors and opticians, one being concern that some of their preferred products may now be considered off-menu. The biggest issue, however, has to be loss of revenue.   Let’s face it—nobody is an EyeMed provider because they pay so well.  (Here’s a sad tidbit:  I pay more for a pedicure at the mall than some of our doctors make for a comprehensive eye exam. What’s wrong with that picture?)   The only thing that made EyeMed at least tolerable was doctors had a chance to make up poor professional services with optical sales.  Now EyeMed is taking that away and wrapping it up in a marketing package labeled “improved” and “innovative.”

EyeMed is promising to increase provider fees under the new structure.  I guess time will tell what EyeMed considers an adequate increase, considering we see $40 exam allowances in almost every state.  The rep we talked to at EyeMed last week did say that they are planning to gradually phase out plans with $40 reimbursements, but he skirted the question when asked what we could expect to see.   I have since seen one EyeMed publication that proposed minimum exam allowances of $50 for new policies they write.  However, existing policies will not change, at least not until the employers’ contracts come up for renewal.

The process is too new to be able to make a valid assessment about how EyeMed’s change will affect doctors’ bottom line.  Doctors no longer have to bear the cost of goods for lenses, so depending on their contract and what products they up-sale, we can only wait to see if doctor reimbursements are high enough to make remaining an EyeMed provider profitable.

Link to EyeMed’s provider manual detailing contract information:  http://www.eyemedrecert.com/Contract/images/Collateral_Addendum_Manual.pdf

When the Affordable Care Act goes into affect on January 1, there will be two very positive components for optometrists. First,  every policy must cover comprehensive eye exams for children up to age 18.  The new federal law labels pediatric eye care as an “essential” benefit–and we couldn’t agree more!  Optometrists should be planning an informational campaign to educate their patients. Get the word out in your practice newsletters,  on hold messages, signs in your exam rooms, etc.  Start to add children to your recall list, and assist your front desk staff by helping them script the importance of eye exams for children.   This has the potential of helping grow your practice as well as providing hundreds of children with a critical service!

The second provision of the new law ends insurance plans discrimination against optometrists.  Starting January 1, no insurance plan can deny payment to optometrists for medical eye care based on licensure. The antidiscrimination statue includes self-funded ERISA plans, like those covering many Detroit-based autoworkers (Chrysler, GM, UAW, etc).  Yeah!  (Note: Insurance payers can still deny medical care if the service is specifically excluded on the policy for all providers.)