PRACTICE MANAGEMENT TIPS FOR SPECIALTY CONTACT LENSES

The management of patients needing specialty contact lenses presents many challenges, not the least of which is ensuring that the patient and practice are getting maximum reimbursement from their insurance regarding covered services. 

In this and future issues of Profit Advisor Dr. Stephanie Woo shares tips on how her office accomplishes high reimbursement and other financial issues for specialty contact lenses.

Prior Authorization

Getting a prior authorization from the vision or medical insurance company is key for you and the patient alike. 

Have these items available before contacting the carrier: 1) patient's diagnosis or diagnoses if more than one, 2) the CPT fitting code you're using, and 3) the V-codes for the contact lenses you’re prescribing where upon the carrier will let you know if its covered benefit or not. 

If not a covered benefit, then the patient costs are going to be all out-of-pocket, making the process easy to explain, presenting what your fees are for services and lenses. 

If told, "Yes, it is a covered benefit," find out what that really means regarding the amount of reimbursement for, as an example, scleral lenses. If contracted with that insurance, is that an acceptable rate? If not, try to speak with someone higher up, or if you've already submitted the claim, contact the claims adjuster to explain why the reimbursement should be higher.

“Overall, it seems like over 95% of reimbursement issues can be solved in advance with prior authorization.”

— STEPHANIE WOO

Originally, we used to get this authorization while the patient was in the office, but it was inefficient.  Now, we do this in advance, acquiring the information prior to the patient’s fitting appointment.

I typically see a patient for a consultation first to determine what kind of disease may be present, and what contact lenses are indicated. They’re then scheduled for their fitting and by the time they return, we'll have a handle on their reimbursement.

If it turns out their insurance is not covering anything, we can call them in advance, communicating that we've done the research and their insurance is not covering this type of service or lenses, and here's the out-of-pocket charges.  The patient can then decide if they’d like to proceed.

Doctor (and patient) time is saved this way since the decision is made in advance, avoiding the uncomfortable situation in the office where the patient is expecting insurance to reimburse, but they aren’t. 

Our office also tracks who the individual is they’ve spoken with at the insurance carrier as a reference point if there are multiple communications. The same for a reference or encounter number, if available. This usually results in the carrier looking into the situation in more detail.

Sometimes, the doctor may need to get directly involved communicating with the insurance carrier, especially if it’s for a higher than usual reimbursement. The carrier will want to know why the fees are what they are and will need to have formal letter along with proper codes to substantiate it. 

Overall, it seems like over 95% of reimbursement issues can be solved in advance with prior authorization.