Billing post-cataract glasses to Medicare Advantage plans

whitekae

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We've been seeing a lot of patients lately with Medicare Advantage plans asking us to bill their glasses post-cataract surgery. Usually we tell these patients no, because we don't participate in DMERC. However, we've recently been advised by one of these companies that for Medicare Advantage patients, it's not necessary for us to participate in DMERC and that (according to them) we are contractually obligated to bill hardware in this way as participating providers.

The reimbursement rates for these plans are of course absolutely miserable and in general will not come close to recouping our costs, much less allowing us to turn even a modest profit. I am aware that may be some way to bill these without having to write off the entire balance of the claims, but I haven't been able to actually test this and would prefer to avoid it altogether if possible given what a nightmare these plans are to deal with even for simple, straightforward billing. (I will do so if necessary, but we opted out of DMERC for a reason.)

I've thought about it a bit, and I wonder whether or not we are really under contractual obligation to participate in this. Strictly speaking as an optometry clinic, we don't actually have either lenses or frames to sell. When a patient places an order, we purchase the frames from a manufacturer and the lenses from an optical lab. We then resell and dispense to the patient for a profit. It seems to me that we probably can't be contractually obligated to purchase frames and lenses for any patient. Is that just wishful thinking on my part, or could we actually just tell patients we're not participating? For that matter, if we did tell patients we don't participate, would we have any leeway at all to sell them private pay glasses, or would this only be possible if we told the patients to go elsewhere?
 

Cheezum51

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You're in a tough spot. Most of the MA plans that I've seen have a carve out for glasses which is handled by Vision Care Plans such as Eyemed or VSP. If you aren't a participating provider for the plan for your non MA patients, I'm not sure if you are automatically enrolled as a participating provider under the MA. The eyeglass plans I've seen have a $150 allowance for the glasses and anything above that amount is paid out of pocket by the patient, with perhaps some discount on that amount or a discount on the total price of the glasses.

You're going to have to somehow find out what the benefits for glasses are for the MA patients you see. I would imagine it's a set amount as I mentioned above but I'm not sure who you would bill it to if it's handled by a VCP you aren't a provider for.

It's important to OD practices to be able to participate with the MA plans since CMS is trying to get about 80% of Medicare patients into this plans over the next couple of years. Unfortunately, many of the MA plans discriminate against ODs and won't allow them on their provider panels.

Tom Cheezum, OD, CPC, COPC
 

whitekae

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You're in a tough spot. Most of the MA plans that I've seen have a carve out for glasses which is handled by Vision Care Plans such as Eyemed or VSP. If you aren't a participating provider for the plan for your non MA patients, I'm not sure if you are automatically enrolled as a participating provider under the MA. The eyeglass plans I've seen have a $150 allowance for the glasses and anything above that amount is paid out of pocket by the patient, with perhaps some discount on that amount or a discount on the total price of the glasses.

You're going to have to somehow find out what the benefits for glasses are for the MA patients you see. I would imagine it's a set amount as I mentioned above but I'm not sure who you would bill it to if it's handled by a VCP you aren't a provider for.

It's important to OD practices to be able to participate with the MA plans since CMS is trying to get about 80% of Medicare patients into this plans over the next couple of years. Unfortunately, many of the MA plans discriminate against ODs and won't allow them on their provider panels.

Tom Cheezum, OD, CPC, COPC
We are participating providers for the MA plans in question, and as you say, many of them either carve out routine vision with VSP or offer a hardware allowance where we can balance bill the patient. The problem I'm running into is that many of these plans also offer a benefit much like Medicare's DME benefit, where they will cover a full pair of glasses after cataract surgery. As with Medicare's benefit, they pay based off their allowed amount and demand that we write off the excess rather than balance bill. For original Medicare, we are able to accept Medicare without participating in this program, but these MA plans don't separate out this benefit. This has led to situations where we get ~$70 on a frame that sells for $600 and costs us $200, and we have to write off the overage.

So far this has happened relatively infrequently, but like you said - CMS is pushing more and more of these plans on people, which means this will probably come up more in the future.
 

Cheezum51

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This is a bad situation when you are losing money like this. If you want to sell glasses to these patients, then you have to set guidelines on which frames and lens types they may choose from under their insurance. Medicare doesn't pay for PALs or any lens coatings. I would restrict these patients to flat top bifocals and inexpensive frames which you can at least make a minimal dispensing fee profit from.
I don't really believe that the insurance contract would require you to provide the patient with whatever frame and lenses they want and then have to accept a money losing level of reimbursement. If, in fact, your contract does say that the patient may choose any frame and lens type and you have to accept their meager payment in full then I would tell the patients that you are happy to examine them but that you are unable to participate in the materials portion of their benefits.

In reality, I believe you're receiving incorrect information from someone at the insurance company if they're telling you that the patient may choose whatever they want and you can't balance bill over the reimbursement provided by the company. As I mentioned before, the plans I'm familiar with gave them a flat $150 towards glasses and the patient had to pay the balance.

Someone isn't getting the correct information to you IMHO.

Tom Cheezum, OD, CPC, COPC
 
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