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3 rd Party Primer 3 rd party basics to answer the questions… Who are the insurers in Nebraska? How do I evaluate 3 PowerPoint Presentation
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3 rd Party Primer 3 rd party basics to answer the questions… Who are the insurers in Nebraska? How do I evaluate 3 rd Party Plans? Should I be a provider? How do I enroll? What exam procedures do insurers require? What services & materials do they pay for?

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3 rd Party Primer 3 rd party basics to answer the questions… Who are the insurers in Nebraska? How do I evaluate 3


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    Presentation Transcript
    1. 3rd Party Primer • 3rd party basics to answer the questions… • Who are the insurers in Nebraska? • How do I evaluate 3rd Party Plans? • Should I be a provider? • How do I enroll? • What exam procedures do insurers require? • What services & materials do they pay for? • What documentation is required? • What is coding & how do I do it? • How do I file a claim? • Where can I go for help?

    2. NOA 3rd Party Primer • Please do not become distraught…. • Complex Subject • Overwhelming at times • Extremely Important • How you get paid • How you stay out of trouble!

    3. NOA 3rd Party Primer • Background • Becoming a Provider • Verification of Coverage • Record Documentation • Filing Claims • References and Resources • Evaluating Insurance Plans before Joining

    4. Types of 3rd Party Payers • Routine Vision Care (prepaid care) • Medical (health insurance coverage) • Combo: Routine & Medical by same 3rd party

    5. Types of 3rd Party Payers • Routine (pre-paid) Care • Cover Exam and materials • Limits on frequency • Limits on materials • Does not pay for medical services (fields, gonioscopy, retinal photos) • Generally file over Internet or may use own claim forms

    6. Types of 3rd Party Payers • Routine examples: • VSP • EyeMed (Eye Care Plan of America) • Optum Health (Spectera) • Medicaid (patients w/o medical diagnosis)

    7. Types of 3rd Party Payers • Medical (health insurance coverage of eye Dx) • Medical diagnosis only (not refractive codes) • Pays for other medical services (fields, gonio) • Rarely pays for materials • File electronically using HIPAA approved format (5010 coming up), or • File on paper CMS-1500 forms • Only okay if less than 10 FTE employees • 5010 coming up

    8. Types of 3rd Party Payers • Medical examples • Blue Cross Blue Shield • Coventry • United Health Care • Medicare • Medicaid medical coverage

    9. Types of 3rd Party Payers • Combination of Routine & Medical coverage • If no medical diagnosis, routine care limitations apply • If medical diagnosis only, medical insurance limitations apply • If both refractive and medical services are provided, respective limitations apply. (varies, however)

    10. Types of 3rd Party Payers • Combination Examples • Conventional Medicaid • Optum Health (Spectera) Routine w/ United Health Care medical • BCBS medical w/ EYEMED routine • VSP routine w/ either CIGNA or BCBS medical • BCBS special policies that include routine care

    11. NOA 3rd Party Primer • Background • Becoming a Provider • Authorization – Verification • Documentation • Filing Claims • References and Resources • Evaluating Insurance Plans before Joining

    12. Should You Become a Provider • Don’t have to be provider; rather can… • Give Patient “super-bill” or print a claim form • Patient pays your fee to you • Patient sends to Insurer • Insurer pays patient their allowable

    13. Should You Become a Provider • Exception: Medicare • If you see a Medicare patient, you must file the claim for the patient.

    14. Should You Become a Provider? • Advantages of not being provider • Full fee • (Medicare has fee limitations on non-providers) • Don’t file claims • (Must file Medicare) • No limit on services provided • (except Medicare) • Medicare: if you see ANY Medicare patients, you must follow ALL Medicare rules.

    15. Should You Become a Provider • Advantages of being provider • On provider list (strong patient resource) • No $ collection problems • Patient happy • Doesn’t have to file own claim • Less $ out-of pocket • Fees seem more reasonable than out-of-plan provider’s fees

    16. Should You Become a Provider • If you are not a provider for an insurer, but you are filing the claim for the patient, you have the choice ofwhether toAccept Assignment • If you Accept Assignment, you agree to accept what an insurer pays, and the insurer pays you directly. • If you do not Accept Assignment, the insurance payment goes to the patient, and the patient (hopefully) pays you.

    17. Should You Become a Provider • If you have signed up to be a provider for a private insurer, you have agreed to accept what they pay, and payments will come directly to you.

    18. Should You Become a Provider • If you see ANY Medicare patients, you must follow ALL Medicare rules. • You have a choice of Participating or not Participating Provider.

    19. Should You Become a Provider • Participating Providers are paid directly by Medicare using their “Par” fee schedule • None-ParticipatingProviders… • Medicare will pay the patient • The patient will (hopefully) pay you. • What you charge a Medicare patient is limited by Medicare’s “limiting charge”.

    20. Should You Become a Provider • Medicare Advantage (MA) • Privatization of Medicare • Medicare charges patient then pays insurance companies a capitation amount per patient • Claims are filed with these MA companies, not with traditional Medicare • Many patients do not understand they are no longer covered directly by Medicare

    21. Should You Become a Provider • Medicare Advantage • Cost to patient may be the same as for traditional Medicare, or there may be an additional charge over traditional Medicare • MA policies may have different co-pay amounts and deductibles than traditional Medicare • Some plans offer additional benefits (dental care, routine vision, drug coverage included)

    22. Should You Become a Provider • Medicare Advantage comes in a variety of types • HMO: Patients see only panel doctors; panel networks small; providers accept HMO’s fees • PPO: Panels more open; some out of panel coverage; providers agree to accept PPO fees • PFFS (Private Fee For Service)…next slide

    23. Should You Become a Provider • Medicare Advantage comes in a variety of types • PFFS (Private Fee For Service): • No networks, • More expensive to patients, • Pays provider per its fee schedule, • Provider does not sign up to be in network • If you accept a PFFS MA patient, you are “deemed” to accept their fee schedule. • If in doubt, check on reimbursement before seeing patient.

    24. Becoming a Provider • A list of the Medicare Advantage plans found in Nebraska can be found at the Nebraska SHIIP web site,http://www.doi.ne.gov/shiip/medsup/medadv.pdf • http://nebraska.aoa.org/prebuilt/noa/2007_04%20Newsletter.pdf

    25. Becoming a Provider • NPI (National Provider Identifier) • Need before enrolling as any provider • Need a separate NPI for • Each doctor (only one NPI for any doctor), • Each office location, • Each separate business entity (optical dispensary may need separate NPI if has a separate tax ID number) • http://www.cms.hhs.gov/NationalProvIdentStand/01_Overview.asp#TopOfPage

    26. Becoming a Provider • NPI (National Provider Identifier) • Exception: Sole Proprietor (Not a PC or partnership, etc.)… • Only one NPI total (represents both doctor and her/his practice). • Get specifics at http://www.cms.hhs.gov/NationalProvIdentStand/01_Overview.asp#TopOfPage

    27. Becoming a Provider • Sole Proprietor • Single NPI includes Dr and Dispensary • Use Taxonomy codes to distinguish • Doctor Code 152W00000X • Optical Dispensary Code 332H00000X • Verify at Source: http://www.wpc-edi.com/codes/taxonomy

    28. Becoming a Provider • NPI (National Provider Identifier) • Information on NPI application must match information on • Medicare B application (855i and 855b) • Medicare DME application (855s) • IRS information (Employer ID number, etc) • NPI enrollment information found at • National Plan and Provider Enumeration System (NPPES) • https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do

    29. Becoming a Provider • Make sure you used correct entity type on NPI application • Entity type 1 for OD and for OD sole proprietor • Entity type 2 for PC and group practice (partnership)

    30. Contacts to Become a Provider • Routine Care(July 2011) • Avesishttp://www.avesis.com/provider_benefits.html • EyeMed (Eyecare Plan of America)http://portal.eyemedvisioncare.com/wps/portal/emweb/providers/become_a_provider • Optum (Spectera)https://www.optumhealthvision.com/providers/OH_Vision_Provider.jsp • Vision Service Plan (VSP)https://www.vsp.com/cms/provider/provider-home.html

    31. Contacts to Become a Provider • Standard Medicaid • Via Nebraska Dept. of Health & Human Services • Both Routine & Medical • All patients age 65 & up • http://www.hhs.state.ne.us/med/providerenrollment.htm

    32. Contacts to Become a Provider • Medicaid Managed Care Plans • Covers all Medicaid patients that are not also covered by Medicare • Nebraska Medicaid has contracted with Coventry Nebraska and Share Advantage health plans to provide managed care in ten eastern Nebraska counties until mid-2012. • Cass • Dodge • Douglas • Gage • Lancaster • Otoe • Sarpy • Saunders • Seward • Washington Beginning Mid-2012, the entire state will be covered by managed care plans.

    33. Contacts to Become a Provider • Medicaid Managed Care Plans • “Share Advantage” • Administered by United HealthCare • Contact: Jeremy Sand, at 402-445-5587, or jeremy_sand@uhc.com.

    34. Contacts to Become a Provider • Medicaid Managed Care Plans • “Coventry Of Nebraska, Inc.” • Administered by Coventry Health Care • Coventry of Nebraska’s “contracting area” call 800-471-0240. 

    35. Contacts to Become a Provider • Medicaid Managed Care Plans’ Routine Vision Care • Block Vision • OD wishing to provide routine vision care to a Medicaid Managed Care client must enroll with Block Vision. • For Block Vision credentialing • Call Adrienne Bennett, VP, Operations at 800-243-1401 x1067; • Emailabennett@blockvision.com .

    36. Contacts to Become a Provider • Medical Coverage • Blue Cross Blue Shield of Nebraskahttp://www.bcbsne.com/Providers/Library/Credentialing.aspx • Midlands Choicehttp://www.midlandschoice.com/Provider/Credentialing/Index.html

    37. Side Note -BCBS Requires Special Form For Retroactive Reimbursement • Apparently BCBS will pay claims retroactive to the date of application for enrollment, but only when their special form is completed. • Credentialing web page at: • http://www.bcbsne.com/Providers/Library/Credentialing.aspx • P.9. January 2009

    38. Contacts to Become a Provider • Medical Coverage • Coventry800 865-2673, press 6 for credentialing • United HealthCare, 877/842-3210, then using a fake tax ID # 471234567, follow their phone voice response. When given the choice, say • First choice, Press 5 or say “…Other” • Next choice Press 1 or say “Credentialing” • Next choice Press 2 say “Medical” • Next choice Press 2 or say “Join network” • UHC convoluted web site found at: http://www.uhc.com/physicians/join_our_network.htm

    39. Contacts to Become a Provider • Medicare • Medicare Part B http://www.wpsmedicare.com/j5macpartb/departments/enrollment/ • Rail Road Medicare Part B 877/288-7600 • http://www.palmettogba.com/palmetto/Providers.nsf/docsCat/Providers~Railroad%20Medicare~Resources~Provider%20Enrollment?open • Medicare Durable Medical Equipment • Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Brochure [PDF,87KB] • https://www.noridianmedicare.com/dme/enroll/

    40. Becoming a Provider • Multiple page application forms with considerable documentation: copies of • Optometry Diploma • State License • NPI (National Provider Identifier) • DEA Registration (need it) • Proof of Malpractice Insurance • Photo ID • …plus more in some cases • Turn-around time: weeks to months

    41. Becoming a Provider • Once Approved you will be given • Provider number • Manuals &/or other (Web) resources • Claim requirements • Explanation of various plans • Other important data • Be sure to read these resources…ignorance is not an excuse for incorrect claims! • Fraudulent filing is a Federal crime.

    42. NOA 3rd Party Primer • Background • Becoming a Provider • Authorization – Verification • Documentation • Filing Claims • References and Resources • Evaluating Insurance Plans before Joining

    43. Authorization – Verification • Need to obtain authorization before providing some services &/or materials • Need to verify that the patient is indeed covered. • Most patients are clueless about coverage • Coverage is via spouse’s employment • Employers change coverage regularly • Carry cards from previous years • Employer HR may inadvertently misinform • Concept of Routine vs. Medical care misunderstood

    44. Authorization – Verification • Receptionist who gets 3rd Party Info from patient is possibly most important person in your office. • Need to photocopy both sides of current cards • Routine Care if they have it • Medical Insurance if they have it

    45. Authorization – Verification • Some new patients will not believe they need to give you medical insurance info since “it doesn’t cover eyes” • Explain that you will file a claim for them if they have any diagnosis where they would benefit from medical coverage.

    46. Authorization – Verification • Authorization for Routine Care: • Call-Fax-Online as directed on card or contract • Sometimes time consuming • Some offices start preliminary testing in the meantime • Authorized for exam, lenses, frame, CLs

    47. Authorization – Verification • Authorization for Medical Care: • Wise to contact to verify coverage. • “Authorization” not needed if you are on panel. • However, some ERISA policies do not cover ODs for medical diagnoses.

    48. Authorization – Verification • Some offices get info ahead of time • Via phone when making appointment • Mail patient forms to complete and bring in with them • Accuracy may be a problem since patient are not knowledgeable about new coverage. • Too many re-dos?

    49. NOA 3rd Party Primer • Background • Becoming a Provider • Authorization – Verification • Documentation of patient encounter • Filing Claims • References and Resources • Evaluating Insurance Plans before Joining

    50. Encounter Documentation • Must document everything you do • Must do everything you document • 3rd Party has right to request your records