Ophthalmology and Optometry Coding Alert

Question: I have found it impossible to find out the allowable charge when your provider does not participate in a plan. In these cases, can we collect our entire fee from the patient at each visit? Or do we need to wait until we get the explanation of benefits (EOB) and bill the patient?

Michigan Subscriber

Answer: Your fee is your fee. The insurance company's allowance should not factor into your charge.

You should collect your full fee from the patient and submit the claim indicating that you do not accept assignment. Send the insurance payment to the patient, reimbursing her the allowable.

Bill the patient: You have no contract with the payer and you are working just with the patient, therefore you can charge your full fee. Remember the patient and her employer contracted with the payer, not you.

Good public relations: If the patient has a problem with the ultimate allowable fees and wants your assistance to appeal for higher reimbursement, encourage her to bring her remittance advices to you so that you can assist her in increasing the payer's allocated allowances. Offering your assistance to the patient is a value-added service for your patients.

-- Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, consulting manager for Pershing, Yoakley, and Associates in Clearwater, Fla.