Ophthalmology and Optometry Coding Alert

Private-Payer Noncovered Services

Question: What should our billing office do when our physician provides an experimental and noncovered service to a patient with private-payer coverage? Is there a waiver similar to Medicare's advance beneficiary notice (ABN) that we should use to ensure payment?

Kentucky Subscriber

Answer: There are several things you can do to ensure reimbursement for services that you know the patient's insurance won't cover:

Require payment from the patient in advance if you are absolutely positive a carrier won't cover the service. Provide financial counseling to the patient if coverage for a service is questionable. Proper education will make sure the patient understands his potential financial obligations and doesn't object to paying if the carrier denies coverage. At this time, you might also arrange a prospective payment plan if the patient is worried about being able to afford the bill.

Ask the patient to sign an ABN-like waiver during the financial counseling session that states the patient will assume responsibility for the costs if his carrier denies coverage. This waiver should provide a written summary of the patient's benefits and outline the specific service(s) that you suspect the carrier will deny. After the patient signs, give him a copy of the waiver and file the original with the chart.

Tip: Some carriers will provide you with an ABN-like waiver for certain noncovered services - you just need to ask. If nothing is available, you can create your own waiver by tweaking Medicare's ABN example for your own specific circumstances.

In summary: Verify patient benefits and explain your billing policies to the patient on the front end to ensure better collections later on. A well-informed patient can't use the excuse "I didn't know."