Wiki Copayments during global period

[kinverlynm@yahoo.com]

Alright, I work for an optometrist and we refer patients to an ophthalmologist to have cataract surgery. After the surgery they come back to us for a 1day Post Op (we have a transfer of care) we bill the same codes as the surgeon with a modifier 55 and RT or LT. My question is, should we be charging a copayment, coinsurance or deductible for their 1 day Post Op visit after cataract surgery? We have not been charging the patients because insurance always pays and the surgeons office informed us we should not charge the patient and as far as I was concerned we should not charge the patient anything during their global period. I recently received an EOB from a Aetna Medicare plan that only paid part of the visit and also had a copayment towards the patient. Do I charge the patient that copayment since the EOB says to or is that incorrect?

 

[Blackhorse]

Did the surgeon bill the procedure with modifier 54? If he didn't, insurance will not know that he transferred the care to your office.

 

[kinverlynm@yahoo.com]

Yes of course we billed everything correctly. It just doesn’t make sense why the EOB would say to charge the patient a copayment when they’re in a global period.

 

[Blackhorse]

If both the surgeon and your office have billed correctly with MOD 54 and 55, you need to call Aetna claim's department to find out why.

 

[thomas7331]

If the EOB says that the patient owes a share, then you can bill them. It may be that this particular patient's plan requires them to pay a portion of surgical charges. I don't think it's that unusual to see something like that.

I agree with the post above - if you services are billed correctly, then you'll need to contact Aetna if you believe that Aetna has made an error. But it's the responsibility of the plan to know what the patient's benefits are and to state that correctly on the EOB, and not really the provider's job to be auditing or second-guessing. The patient should know their own plan benefits and they should be the ones to take it up with their payer if they feel the insurance did not pay correctly for the services they received.