Wiki Collecting Copayments upfront

[schaunarae]

I work for a small eye clinic that has an Ophthalmologist who only sees patients for medical reasons/cataract surgeries and 3 Optometrists. I'm the newest biller/coder to the clinic and have been doing the A/R. They don't seem to collect copays upfront and their A/R is not looking good on the copayment end. I asked how they do it and she said they typically ask for VSP, Avesis, and Davis copayments, but not for medical upfront. They get it on the backend. Im thinking its because my lead doesn't want to put so much on the insurance verifying gal (who also answers phones all day). BUT this is becoming a huge issue. I have a few questions before I bring this up to my Administrator:

1. Is an Optometrist considered a physician visit copay or specialist copay when we bill the patients medical insurance?
2. When verifying insurance, do you use portals or call in to find out what the patients current copayment is?
3. How do you determine the visit is going to stay routine vs medical if you collect copayment upon check in? How do you determine which copay to collect if they come in for a Routine (say VSP 10$) but it turns medical so I have to bill their BCBS? The front desk girl had already taken their 10$ copayment for VSP, but when it gets to me it's to be billed medical?

Any advice will help. This is my first go around working with an eye clinic, although I'm 7 months into my job, its still mind boggling me some days after 10 years of easy outpatient coding (no billing). haha! Thanks!

 

[Cheezum51]

Before any patient comes in, you should collect their vision plan and major medical information and check copays and deductibles so you know what to collect at the time of service. If you don't have that up front, your AR gets out of hand very quickly plus the expense of billing is high. Another issue, if you don't collect these on DOS, is trying to get patients to pay when billed later. Many will claim ignorance about their deductible and expect you to write it off. After all, all doctors are millionaires. Right?

In answer to your questions: 1) ODs are considered specialists when it comes to copays
2) Some offices use the insurer portals. Many are using Availity which allows access to many different insurance companies and their plans. There are other services as well.
3) How the visit is billed depends on the Chief Complaint which may be difficult to determine before the patients are taken back for pre testing. However, if you have an established patient who was previously diagnosed with cataracts, glaucoma or some other pathology, when they come back, they're medical and they can use their vision plan benefits for any optical goods if they can be refracted. Also, if they are medical but can be refracted, VSP will often allow you to do Coordination of Benefits where you bill the medical for the exam and refraction (only use refractive codes on the 92015 and medical diagnosis codes for the exam). When the medical denies the refraction, you can bill VSP for the exam and refraction and it will often pay a portion of the copay along with whatever it allows for the refraction.

Hope this helps.

Tom Cheezum, OD, CPC, COPC

diagnosis codes, diagnosis coding