Wiki No Copays for Eye exams related to Diabetes?

[edmedbilling]

I recently had a payer Regence Medavantage plan call me and say that we should not charge copays for diabetic eye exams. I can't seem to find any ruling about this from Medicare or the payer.

Anyone hear of this? Does the dr need to be treating or monitoring the pt for Diabetes?

Thanks,
Edward

 

[thomas7331]

Diabetic eye exams are not one of the preventive services that are required to be paid in full by plans, so there is not going to be a ruling on this from Medicare. Regular Medicare does not have copays, and the Advantage plans set up their own cost-share arrangements for the plans that they offer, so whether or not a patient has a copay for this is something that is going to be specific to each patient's particular plan and how their benefits are set up. So you should charge a copay if the patient's insurance company or the EOB for the service says that the patient owes one, and not charge one if they don't. I would have to assume that if this plan contacted you, that was because they cover these services in full for their patients. I'm not sure why the payer would call you on this though, because if your office had charged a copay and then the insurance paid the claim in full with no copay, then that should have created a credit balance and a refund to the patient. But perhaps a patient had complained that they were charged for something that they did not owe and never received a credit back?

 

[edmedbilling]

thomas7331: Thank you for your reply. That makes sense now. It was a confluence of confusion started by the patient when she read she had "vision" benefits and called her insurance thinking she was charged a copay for a vision visit. She did not understand that there is a difference between a medical vision visit and a routine vision visit. Further complicated the issue is that our front marked the visit as a diabetic exam when it was not. It's all been resolved now.

Thank you!

Edward