Medical Coding and Billing Implementation (45198-PM)

AdminWolf

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Lecturer: @Steven Nelson

The purpose of this course is the give a roadmap for the implementation of medical billing protocols. It’s designed for those new to medical billing to give a step-by-step guide for credentialing and office procedures related to patient handling. It will give an overview of the necessary steps to becoming a medical insurance provider as well as patient intake paperwork and phone scripts and office worker training.

Register for CEwire2015
to watch the recorded lecture & get CE credit through August 17, 2015.

Discuss the lecture and ask questions in the thread below.
 
Sep 25, 2011
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An Anonymous Poster writes...

I'm listening to his class right now.

Around minute 26 and after that he discusses how you have to charge the same fees for cash or insurance patients. You need lots of signatures to back up what you told patient and what the patient agreed to.

This is too funny. A few years ago my corporate contract was yanked because of this very topic. My office assistant really did tell patients ahead of time what the fees could be, and we had lots of forms to read and have patient sign, but when patietns complained, all corporate cared about was complaints.

I told them I can't commit insurance fraud and they agreed with that. I showed them the forms and signatures I received. I still got the boot due to corporate BS.
 

Steve Silberberg

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Well he was right. People may not want to hear it but don't shoot the expert messenger
 

Steven Nelson

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Oct 26, 2007
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An Anonymous Poster writes...

I'm listening to his class right now.

Around minute 26 and after that he discusses how you have to charge the same fees for cash or insurance patients. You need lots of signatures to back up what you told patient and what the patient agreed to.

This is too funny. A few years ago my corporate contract was yanked because of this very topic. My office assistant really did tell patients ahead of time what the fees could be, and we had lots of forms to read and have patient sign, but when patietns complained, all corporate cared about was complaints.

I told them I can't commit insurance fraud and they agreed with that. I showed them the forms and signatures I received. I still got the boot due to corporate BS.

Sometimes they break the rules and there's no denying that. The thing you have to remember is that it won't be THEM that's on the hook when the auditor comes knocking at your door. Your name, your claim, your penalty.

That said, if you can PROVE that, I'd sue their pants off.
 

Steve Howard

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Mar 5, 2008
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How do the doctors at America's Best get around this. They advertise a free eye exam, so won't insurance recognize this as their usual and customary fee. So will Superior Vision pay them $0 for the exam?
 

Steven Nelson

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How do the doctors at America's Best get around this. They advertise a free eye exam, so won't insurance recognize this as their usual and customary fee. So will Superior Vision pay them $0 for the exam?

That's why it's not really "free." They take the exam fee off of the glasses and pay the doctor directly. What I'D like to know is that in those areas where they take medical insurance, are they billing what their corporate office pays them? It's ok to ACCEPT lower reimbursements, but you can't BILL for less especially if they are seeing medical patients.
 

Steve Silberberg

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Jan 2, 2012
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That's why it's not really "free." They take the exam fee off of the glasses and pay the doctor directly. What I'D like to know is that in those areas where they take medical insurance, are they billing what their corporate office pays them? It's ok to ACCEPT lower reimbursements, but you can't BILL for less especially if they are seeing medical patients.
Other things differ depending on the State Steve. In NJ thye cannot be employed by America's Best so an OMD sets up a dummy corp and employes them They break HIPAA rules by just handing the record to the opticians not even writing an RX at least from a situation I worked on last year
 

Steven Nelson

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I still got the boot due to corporate BS.

Sort of a sidebar, but what was the result? Most of the ODs that I know that "get booted" find it was the best thing that ever happened to them. Partially because obviously what they left sucked, but also because it gave them the initiative to do what they REALLY wanted to do.
 

Lisa Shin

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how did you like the lecture? Did you find it helpful? Any pearls to take away?
Thorough & practical. My take aways were: scheduling for specific insurance, documenting to avoid audit failures, follow-ups for allergies.
1. how would you know if their BCBS covers the 92015 for cataract patients? Would it be apparent on the benefits page? I've never billed 92015 to a medical plan.
2. I have not found an easy way to find out if patients have met their Medicare deductible (without being on hold forever). We usually assume that they haven't in January-February and/or take their word for it after that. Availity is great for BCBS deductibles.
3. how would you handle a patient who tells you, "I'm here to use my vision plan, not my medical plan. the other place refused to..." have you ever had a patient read your vision vs medical form & get upset about it?
 

Steven Nelson

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Oct 26, 2007
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Thorough & practical. My take aways were: scheduling for specific insurance, documenting to avoid audit failures, follow-ups for allergies.
1. how would you know if their BCBS covers the 92015 for cataract patients? Would it be apparent on the benefits page? I've never billed 92015 to a medical plan.
2. I have not found an easy way to find out if patients have met their Medicare deductible (without being on hold forever). We usually assume that they haven't in January-February and/or take their word for it after that. Availity is great for BCBS deductibles.
3. how would you handle a patient who tells you, "I'm here to use my vision plan, not my medical plan. the other place refused to..." have you ever had a patient read your vision vs medical form & get upset about it?

Thanks. More than anything, I was going for practical. If it's not practical, it's impossible to implement.

Followups in GENERAL are something we could all be better about. Seeing diabetics more frequently, people on higher risk meds like plaquenil, seroquel, oral steroids etc, allergies, dry eye. Those are all things that warrant more attention than we generally give them and our schedules could use the infusion with medical visits.

1) To find out if it's covered, you almost ALWAYS have to call and ask. It's generally not stated as a "benefit" because it's considered to be a medical test and most of the medical insurers that pay for it almost do so by accident.

2) VisionWeb has a portal to find out about Medicare deductibles. The nice thing is that those patients are generally pretty good about paying bills AND they only have a $149 deductible anyway, so it's pretty much covered after their first doctor visit of the year. That said, keep in mind that whether it's VisionWeb or even on hold, what they tell you may not be accurate because of processing time. They're looking it up in their IVR just like you would, so don't be surprised if your R&S report shows something different than you thought.

One strategy you can use is to only bill them that 20% and refraction (assuming they don't have a co-insurance which may mean they pay you nothing at the time of the visit - again, stuff that you generally have to call to find out) and then if they owe you more as shown on the R&S, make a copy of that and mail it with an invoice. They're generally pretty good about paying it.

On co-insurances. You'll sometimes encounter a secondary that neither of you knew about and get a mystery check for $21 or something. In that case, you'll need to call the patient to let them know and issue a refund for that amount. Sometimes they cover the 20% and refraction, sometimes the 20%, sometimes just a portion. You really never know until the check comes in.

3) All you can do is decide how far you're willing to let them push you. I've had patients that get upset because they want to use their vision plan, but I point out the part of the form that states that it's the INSURANCE that makes those rules, not me and I'm legally obligated to follow their rules. It's really a business decision as to whether you stand your ground. Honestly, some of it you have to play by ear. The NICE thing about it, though, is that over time, you tend to cull those folks out of your schedule anyway especially if you're filling it with appropriate followups.

I think what's important to keep in mind that these folks will need REFRACTIVE care as well, so just because they're there for glaucoma, that doesn't mean that they don't want to SEE well also so those ancillary visits are also opportunities for them to be in your optical or to see promotional info for stuff like ortho-k or whatever.

The wonderful thing about being an optometrist is that we DON'T have to choose whether we're vision or medical. We're excellent at BOTH and that's why I mentioned that in the lecture. Don't let yourself be pigeonholed by those that say you're either a refractive doctor or a junior OMD. That's a stupid and professionally myopic attitude. Be both. Be excellent at both.
 
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