Optometry Coding & Billing Alert

Prevent hundreds from running out the door with these expert tips.

Note: For Part 1, see Optometry Coding & Billing Alert, Vol. 7, No. 4.

There are some insurance companies that your practice just doesnt want to do business with. So, if your optometrists are seeing patients with insurance you do not participate with, how can you ensure that your practice still gets paid?

Problem: When you are a non-participating provider with a payer, the patient directly receives the check from the insurance company. But some patients do not, then, use those funds to pay the bill your practice sends. What are your options? Previously, we covered two choices: collecting at the time of service, and sending the patient to collections. Here are two more tips from our experts.

Option 3: Accept Assignment

If you do not collect payment at time of service for whatever reason, you can submit the claims to the payer accepting assignment if the patient agreed to allow you to accept assignment, even though you do not participate with that payer.

The patient will have to sign a form allowing you to accept assignment, and that form should be part of your standard initial patient packet, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network.

How it works: If the payer is Medicare and you do not participate, you will be paid less if you accept assignment, but you will be guaranteed to get paid and not have to worry about collection, Cobuzzi explains.

Other third-party payers will pay the practice the same as they would have paid the patient, and you will only have to balance bill the patient and perhaps have to send them to collections or small claims court for her deductible or coinsurance (copayments). And still other third-party payers, for example Horizon Blue Cross Blue Shield of New Jersey, will not pay a physician even if the claim has an assignment of benefits to the physician. In a situation like this, you will not be able to accept assignment and will need to look at one of the other three options.

Option 4: Par With the Payer

Sometimes it may not make sense to send a patients account to collections. Your practice should regularly evaluate the payers you contract with (and dont contract with) as well as your patient base. You may find in some cases that participating with a particular insurance company will save the practice time, money, and headaches in the end.

Its unfortunate, but sending them to collections or small claims court cuts the amount you would get almost to the point that it may be worth participating with the insurance companies, says Robin Yazell, CPC, billing supervisor at a practice in Syracuse, N.Y. I know Id much rather fight the insurance companies to get our money than fight with the patients. In this economy, Im afraid collecting from patients will only get worse.

If you have the patients sign a financial agreement (which we have on our registration/demographic sheet) that states they will be responsible for any cost incurred by the collection agency/attorney, you can receive full payment for services rendered, and they [the patients] pay the collection agency fee, says Lori Braidic, billing manager for Womens Care Center Of Columbus in Ohio.

Caution: Before you consider participating with the payer, look at your operations, Cobuzzi says. Are you sending patients to collections because you are not doing a good enough job of collecting at time of service and you could put better processes and procedures in place? Or are you putting patients in collection because you dont have the opportunity to collect at time of service because you have such a large hospital-based patient base? If the second is true, there may be a case to consider participating.

If the first is the case, evaluate your processes, your training, and your communications with your patients.