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tcoleman6

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I work for an Optometry practice that is doing a lot more medical billing due to the addition of some new machines. Many of our patients have both a medical plan and an optical plan like Eyemed or VSP and frequently they have different co-pays, usually the routine being lower. A person of authority in the office has taken to accepting the lower co-pay from the routine plan, but billing the medical plan with a medical Dx and E&M...in effect, waiving part of the co-pay for the medical plan. I'm experienced enough to realize this is not a good policy, however I'm not sure just how serious this situation could be. As the only certified coder in the office, I'm concerned this could potentially cost me that certification. Any advice on the subject would be appreciated. It's my first coding job and I don't want to over-react.

Thanks.
 
Dear Biller,

The person in charge should be made aware of the consequences of waiving or accepting partial copays or deductibles. Insurance co. do monitor this behavior and will drop the provider and the other providers, if it is a group practice. I know from exp. I warned our dr. for months before all 4 of our drs in group were dropped because of ONE provider. I would suggest that you ask the office/P.A. to post sign in lobby that all copays, coinsurance, etc. are required when services are rendered.

signed,
here to help
 
I suggest you take this up to the top. Head physician? Administrator? Compliance person? This other person is also losing money for the practice. Maybe it can come out of her/his paycheck.
 
Thanks so much for the replies. I had already spoken with the people at the top using the exact same points and arguments you both stated, but was pretty much told that's how they want to operate. I'm relocating next year, so my real concern is that this not affect my ability to get a new job later. Until then, I'll continue to try to educate them on proper procedures and lost revenue.

Thanks again!
 
You are right, this is noncompliant behavior, and can result in breach of contract penalties. I am on the compliance team at the billing service where I work and the only other thing I would advise is that you document your concerns and communication of those concerns to your compliance officer and administrator. That way if/when there are consequences, you will be protected.
 
If your billing a medical plan (primary) & Vision plan (secondary) you actually have to collect both copays (this was what I was told by a vision plan). I know on the eobs we received from the vision plan (paying as secondary), they still took out the pt copay before they pd us. you may want to double check your eobs. This could also back up your argument.
 
Thanks for the information. I'm not sure we've ever billed a vision plan as secondary insurance, but I'll certainly check into it.
 
drakena74 said:
If your billing a medical plan (primary) & Vision plan (secondary) you actually have to collect both copays (this was what I was told by a vision plan). I know on the eobs we received from the vision plan (paying as secondary), they still took out the pt copay before they pd us. you may want to double check your eobs. This could also back up your argument.
Click to expand...

I have not been successful billing a routine plan secondary to a medical plan. The primary diagnosis is either medical or routine, and either way, only one insurance will pay.

The only way I have been successful is to bill the exam to the medical plan and the refraction to the vision plan. Most vision plans have difficulty with this, but after a few phone calls, it usually works out. If the vision plan assesses a copay, of course, you must collect it.
 
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