3rd party primer - nebraska home convention/2017/handouts... · routine care avesis eyemed (eyecare...

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3rd Party Primer• 3rd party basics to answer the questions…

– Should I be a 3rd party provider?– How do I evaluate 3rd Party Plans?– Who are the insurers in Nebraska? – How do I enroll? – What exam procedures do insurers require? – What services & materials do they pay for? – What documentation is required? – What is coding & how do I do it? – How do I file a claim? – Where can I go for help?

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Resource For This Presentation The 3rd Party arena is complex

As when eating an elephant, it is best digested in small portions

Dr. Quack has thus created ten 15-20 minute videos to educate 3rd party novices

Today’s presentation is an overview & explanation of those videos

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NOA 3rd Party Web Page 3 Educational Videos 4

Educational Videos 5 Video 1Should I Become a 3rd Party Provider?The advantages, and disadvantages of becoming a 3rd Party Provider.

YouTube Presentation, with audio commentary, but inactive website links

Live links below video links

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Should You Become a Provider? Don’t have to be provider; rather can…

• Give Patient “super-bill” or a printed claim form

• Patient pays your fee to you

• Patient sends claim to Insurer

• Insurer pays patient their allowable

Exception: Medicare

If you see a Medicare patient, you must file the claim for the patient.

7 Should You Become a Provider?Advantages of being a provider On provider list (strong patient resource) Fewer $ collection problems Patient happy

Doesn’t have to file own claimLess $ out-of-pocket Fees seem more reasonable than out-of-plan

provider’s fees

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Types of 3rd Party Payers

Routine (pre-paid) Care• Cover Exam and materials• Limits on frequency • Limits on materials• Does not pay for medical services

(fields, gonioscopy, retinal photos)• Generally file over Internet or may use

own claim forms

9 Types of 3rd Party Payers

Medical (health insurance coverage of eye Dx)

• Medical diagnosis only (not refractive codes)

• Pays for other medical services (fields, photos)

• Rarely pays for materials

• File electronically using HIPAA approved format

• File on paper CMS-1500 forms

• Only okay if less than 10 FTE employees

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Should You Become a MEDICARE Provider?

If you see ANY Medicare patients, you must follow ALL Medicare rules.

You have a choice of Participating or not Participating Medicare Provider.

11 Should You Become a MEDICARE Provider?

Participating Providers are paid directly by Medicare using their “Par” fee schedule

None-Participating Providers…• Medicare will pay the patient• The patient will (hopefully) pay you.• What you charge a Medicare patient is

limited by Medicare’s “limiting charge”. You cannot bill beyond the limiting charge.

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Medicare Advantage comes in a variety of types• HMO: Patients see only HMO panel doctors;

panel networks small; providers accept HMO’s fees

• PPO: Panels more open; some out of panel coverage; providers agree to accept PPO fees

• PFFS: (Private Fee For Service)

13Should You Become a MEDICARE ADVANTAGE Provider?

Video 2How to Become a 3rd Party Provider

What you must do to become a 3rd Party Provider.



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Enrolling as a Provider

Multiple page application forms with considerable documentation: copies of

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•NPI (National Provider Identifier)

•Optometry Diploma

•State License

•DEA Registration (need it)

•Proof of Malpractice Insurance

•Photo ID

…plus more in most cases

•Turn-around time: weeks to months

Contacts to Become a Provider

Routine Care

Avesis

EyeMed (Eyecare Plan of America)

Optum (Spectera)

Vision Service Plan (VSP)

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Contacts to Become a Provider Medical Coverage Medicare

Medicare Part B Wisconsin Physician Services GHA

Rail Road Medicare Part B 877/288-7600

Medicare Durable Medical Equipment

Brochure

Noridian Durable Medical Equipment

17 Contacts to Become a Provider

Standard Medicaid• Via Nebraska Dept. of Health & Human

Services • Both Routine & Medical • Patients age 65+ &/or in nursing home

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Medicaid Managed Care Organizations (MCOs)

MCOs cover all Medicaid patients that are not also covered by Medicare.

MCOs cover

Medical Diagnoses

Routine Care



There are three MCOs under Nebraska Medicaid’s new “Heritage Health” managed care system. To see all Medicaid patients, you will need to enroll with all three MCOs.

Total Care, subcontracting routine and medical eyecare to Envolve

WellCare, subcontracting routine and medical care to Avesis

United HealthCare Community Plan, subcontracting routine vision to Superior Vision (aka Block Vision)

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For the Total Care MCO, enroll with subcontractor ENVOLVE for both routine and medical eye care Scott Chandler, RPh, Director Network Development

Envolve Vision

112 Zebulon Court

Rocky Mount, NC 27804

Direct: 252-544-9329

Fax: 844-698-9702

[email protected]

envolvevision.com



For the WellCare MCO, enroll with subcontractor AVESISfor both routine and medical eye care

Avesis � [email protected] � 1-800-643-1132 Ext. 11752

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Contacts to Become a ProviderMedicaid Managed Care Organizations (MCOs)

For the United HealthCare Community Plan MCO, you will need to enroll with UHC and Superior Vision

United HealthCare Community Plan (medical eyecare),

You can apply online or by calling 877-842-3210.

Say or enter your tax identification (TIN) or social security number (SSN)

and follow these prompts: health care professional services > credentialing > request for participation.

Superior Vision (routine eyecare) Contact information on previous routine care slide

23 Video 3: Filing Claims, Part 1CMS-1500 Claim Form and the Electronic Equivalent; Diagnosis Coding

Explanation of the CMS-1500 claim form and its electronic equivalent. Also, an explanation of Diagnosis Coding



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CMS-1500

26TOP OF CMS-1500 Insurance Type

27BOTTOM CMS-1500 Diagnosis Data Medicare Provider Manual Billing InstructionsIncluding what data in which box

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Medicaid Provider Manual Billing InstructionsWhat data in which boxMedicaid Online Services .

Billing Instructions

Bulletins

Payment Rules

Vision Care Fee Schedule

Vision Care Rules

29 Diagnosis Coding• ICD-10-CM • International Classification of Diseases

– Refractive Diagnosis Codes

– Disease Diagnosis Codes

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2018 NOA ICD-10 Coding Resource

31Video 4: Filing Claims, Part 292000 Exam Codes

The basics of Services and Procedures coding.

Also, coding the 92000 examination codes, including an unofficial 92000 coding score sheet created by Dr. Quack.


Live links below video links.

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33BOTTOM CMS-1500 Service & Materials Supplied Reference 34

Current Procedural Terminology, or CPT

Updated annually, so needs to be replaced annually.

Covers

•Examination coding,

•Ancillary testing coding

•Some dispensing and CL coding.

Medical Examination Coding 35

New Estab

92002 (int) 92012 (int)

92004 (cmp) 92014 (cmp)

92000

Ophthalmology Codes

Intermediate

Comprehensive

Chief Complaint

A brief explanation of why the patient is in the office.

The Chief Complaint drives the encounter

To bill a medical insurer, the chief complaint must demonstrate Medical Necessity

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blepharitis 1 1

cartaract 1 2

glaucoma 41

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92000 Score Sheet

Video 5: Filing Claims, Part 399000 E&M Exam Codes

Coding the 99000 Evaluation and Management examination codes, including an unofficial 99000 coding score sheet created by Dr. Quack. YouTube Presentation, with audio commentary,

but inactive website links


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Reference 43

Current Procedural Terminology, or CPT

Updated annually, so needs to be replaced annually.

Covers

•Examination coding,

•Ancillary testing coding

•Some dispensing and CL coding.

Evaluation and Management Coding

• There are three Key Components– History– Examination– Decision Making

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99000 Evaluation and Management Codes

Chief Complaint

A brief explanation of why the patient is in the office.

The Chief Complaint drives the encounter

To bill a medical insurer, the chief complaint must demonstrate Medical Necessity

45 E&M Score Sheet

Dr. Quack’s Evaluation and Management score sheet is…

Based on the 1997 E&M Guidelines for single organ systems

Unofficial, but should be helpful in determining the level of E&M exam code

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47OU

hazymod.constant

night drivingheadlights

CataractGlaucomaDry AMD

orhalos

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cataract 1

1

1

1 1

2

blepharitis

glaucoma susp.

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<1

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Video 6: Filing Claims, Part 4 Should I use the 92000 or 99000 Codes Discusses general advantages and limitations of the

92000 ophthalmology exam codes versus the 99000 E&M exam codes.



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6 99000 vs. 92000

• In general, the 99000 codes are more concrete, requiring less subjective judgment

• But these concrete requirements may necessitate tests or procedures not required by comparable 92000 comprehensive codes.(dilation)

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99000 vs. 92000The 92000 codes for a comprehensive exam require a

“diagnostic and treatment program” while the 99000 codes do not.

• When following a patient chronic conditions that require…

• no billable diagnostic testing and

• no treatment,

• …it is difficult to code comprehensive 92000 codes.

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• Never examine and bill simply to maximize reimbursement rates…

• To do so is fraudulent, and can lead to severe monetary penalties and possible criminal charges.

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Video 7: Filing Claims, Part 5 CPT Modifiers

Explains the use of CPT Modifiers commonly used in an optometric practice.



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7 56BOTTOM CMS-1500 Service & Materials Supplied

57WPS Table of ModifiersModifier 24

• Unrelated Evaluation & Management Service by the Same Physician During a Postoperative Period.

Example: GLC follow-up exam and fields during cataract post-op period.

• Cataracts 90 days

• Punctal plugs 10 days

• Foreign body 0 days

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Modifier TC

• Example: technician performing 92083-TC while patient’s own OD is not on the premises

• Cannot charge Medicare if nodoctors are on the premises

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OD and OMD codes that qualify

Sensorimotor Exam 92060TC

Orthoptic/Pleoptic 92065TC

Visual Fields 92081,2,3TC

Scanning Laser 92135TC

Fundus Photos 92250TC

Color Vision 92283TC

Dark Adaptation 92284TC

External Photography 92285TC

Technical Component

Modifier GY /

Used to indicate that the item or service is statutorily non-covered (not a Medicare Benefit).

• It is filed to instigate subsequent payment by another insurer.

• It results in the patient being notified the service or material is not a Medicare benefit.

• Example: refraction 92015GY.

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Video 8: Filing Claims, Part 6 Medicare Supplier Codes

Discusses coding Medicare Durable Medical Equipment as used for post-op glasses and contact lenses.



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8 Who Manages Medicare Durable Medical Equipment (DME) DME Suppliers managed by the National

Supplier Clearinghouse (NSC), currently administered by PalmettoGBA.

DME Claims handled by our DME contractor, Noridian Administrative Services.

Used for post-op glasses or CL claims.

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63Our Medicare Supplier Administrative Contractor…

https://med.noridianmedicare.com/web/jddme/policies

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https://med.noridianmedicare.com/web/jddme/policies/lcd/active

Local Coverage Determination Policy Article HCPCS Codes Covered

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Local Coverage Determination

https://med.noridianmedicare.com/web/jddme/policies/lcd/active/refractive-lenses

66Policy Article

https://med.noridianmedicare.com/web/jddme/policies/lcd/active/refractive-lenses#Policy Article

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Cost to Become a Medicare DME Supplier

To enroll as a supplier: ~$500 every three years

Cost of Surety Bond (if needed…)

67 Video 9: Other 3rd Party Resources

Other 3rd Party Resources

NOA, Medicare, Medicaid, and other resources to help you understand 3rd party requirements and file 3rd party claims.



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Coding References

• CPT (Current Procedural Terminology)– Service Codes

• 92000 Ophthalmology• 99000 Evaluation & Mgmt

– Surgical Procedure Codes• 65205 Removal of FB• 67820 Epilation of Lashes

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• ICD-10-CM• International Classification of Diseases

– Refractive Diagnosis Codes– Disease Diagnosis Codes

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CMS: Medicare Learning Network 71 NE Medicare B References

Local Coverage Determinations

Local Coverage Determinations (LCDs)

o Standardizes what Medicare considers “Reasonable and Necessary”

o Lists very specific coding requirements for those services & procedures

o Blepharoplasty, Brow Lift

o OCT---Scanning Computerized OphthalmicDiagnostic Imaging (SCODI)

o Visual Fields

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NE Medicare B ReferencesWPS Medicare Communiqué Quarterly Newsletter

All Provider are legally responsible for reading and abiding by this document.

• CMS policy

• Coding requirements

• Documentation requirements

• Contact information

• Billing requirements

73 NE Medicaid References

Medicaid Provider Manual – Vision Care

Visual Care Services

Payment Rules

Fee Schedule

Billing Instructions

Bulletins (bottom of page)

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NOA References

NOA 3rd Party Newsletters Medicare & Medicaid Updates MIPS Medicare bonus vs. cuts Coding Unique to Nebraska Electronic Health Records ICD-10 HIPAA Q & A Page

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Monthly Newsletter Email

NOA 3rd Party Web Page 77 78NOA 3rd Party Web Page

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3rd Party Index Page

CAN BE SEARCHED USING… CNTRL-F Search Function ALPHABETICAL Index TOPICAL Index

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May 2017 Issue of 3rd

Party News

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Links to 13 pages of 3rd Party Resources

NOA 3rd Party Consultation

• Contact Methods– Email [email protected]– Fax 402 464-1214 (contact Ed first)

• Cover page: Contains PHI-for Dr. Schneider’s eyes only

• 24 hour turn-around time

81 Video 10Evaluating 3rd Party Plans

Some things to consider before joining a 3rd Party Panel

Quick review of the basics Dr. Quack suggests you create an Excel

spreadsheet when considering enrollment in various 3rd Party Plans

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A Fundamental Issue: What it costs you to do business.

Chair-cost-per-hour• What does it cost per hour to have patient(s) sitting in your

exam chair? (Worse yet: not sitting in your exam chair…)

Dispensary-cost-per-hour• What does it cost per hour to operate your dispensary?

83 Revenue per Patient (RPP)

Routine Care (VSP) Examination Covered Glasses Additional Pairs Contact Lenses Solutions

• In addition, Patient’s Medical Ins. may cover: Additional testing Medical treatment &

follow-up

Medical Care (BCBS) Examination Additional testing Medical treatment

• Patient may also purchase Prescription Glasses Additional Pairs Contact Lenses Solutions

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Additional Online ResourceFrom the AMA Practice Management Center… “15 things to consider before signing a managed care

contract”

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http://www.niatx.net/toolkits/provider/Contracting15questions.pdf

Thank You for Listening!!• Questions? Need Help? Then Contact Dr. Quack at…

[email protected]• 24 hour turn-around time

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