Read more from the Q&A issue

• Methodology: Keep the questions coming
• How can optometrists efficiently schedule ocular disease patients in light of the COVID-19 pandemic?
• How can optometrists create a successful dry eye disease spa?
• How can an optometrist include the patient’s opinion when it comes to glaucoma treatment?
• How can O.D.s differentiate the neovascular form of AMD from similar diseases?
• How can an optometrist obtain diabetic patient referrals from a primary care physician?
• What should optometrists know about effective management of myopia?
• What is the value optometrists can provide and communicate for the fee charged?
• How can optometrists set up an appropriate fee schedule for specialty contact lenses?
• How can O.D.s get more engaged in luxury frame sales?
• How can optometrists get more new patients?
• How can an optometrist create a successful practice sans third party health plans?

A: To create a system for quick and efficient coding, you’ll want to obtain credentials, seek the rulebooks, communicate procedures with the patient and take action on accounts receivable. Let’s dig in.

OBTAIN CREDENTIALS

Step one, before doing anything else coding related, is to register with CAQH. When you register with CAQH, at proview.caqh.org/Login/Index?ReturnUrl=/ , you will see what information the organization requires from you to get started. (When you credential a new doctor, this is one of the first steps you need to take as well.) CAQH requires an update from you regularly. Of note: If you have turned this task over to one of your team members, I would advise you log in with them at least once a year to ensure the accurate contact person, email address, phone number, etc.

Once registered with CAQH, optometrists can then seek credentials from individual insurance plans; you’ll need to be certified by each plan you choose to carry in your office. Be certain you enter the same data for each insurance plan, for example, use the same address, phone number and contact person, as not doing so can cause challenges. Also, have handy all your important information, such as NPIs, both group and individual, tax ID, license number and business information. Print and scan everything you enter, so you have hard copies and/or digital copies saved for your records.

Print the contract and manual for each plan, and save changes as they are made throughout your time as a provider. Many times, an area I see for improvement in practices is staying up-to-date with changes in billing processes, such as new requirements for medically necessary contact lenses or new requirements for covered spectacle lenses. Each change made must be followed immediately and correctly to be certain of compliance with billing practices and, as a result, receipt of correct payments.

Register for updates with each insurance plan. In the old days, our updates would be sent via fax. Now, however, you receive updates to the email you have registered with the insurance.

SEEK THE RULEBOOKS

Look up, print and save the Local Coverage Determination (LCD) for your state, and print each one that applies to procedures you perform in your practice. (The LCD is simply Medicare’s payment vs. the non-payment rule book. Thus, any billing and coding compliance protocol you build in your practice should follow these guidelines to abide by your provider contract with Medicare beneficiary coverage.)

A good plan for the beginning of every year is to review the LCD for each procedure offered in your practice. To find the LCD by state, visit go.cms.gov/2F6zthw . In the LCD, you will find these coverage guidelines, including coverage indications, limitations and/or definitions of medical necessity. In some states, there may not be an LCD for a specific procedure. In such cases, follow the national coverage determination, or NCD, for that procedure.

I recommend keeping the LCD for the current year until you are past the time you may be audited, which can range from a four- to 10-year look-back period.

For example, if you are audited regarding records from date of service 2015, it is important to have kept the LCD for that year to be certain you are referencing rules that were in place at that time and not the rules in place today, as they could be different.

Each carrier has payment policies and rules they follow for processing claims involving many of the common procedures we provide in our practices. For insurance plans other than Medicare, look at your manual for details on coverage, reimbursement amounts and proper billing practices. Remember, the rules can be different for each and vary by state.

COMMUNICATE PROCEDURES TO PATIENTS

The following protocol is an example of how to keep the patient in the loop regarding their charges within your practice.

1. Collect all insurance and managed vision care plan information from each patient at the time the appointment is made.
2. Verify all benefits before the patient visit.
3. Notify patients — before they arrive — of the expected costs for the visit.
4. Explain to patients their insurance coverage again at the time of their visits before they see the doctor.
5. Obtain all plan-required patient signatures that establish patients' consent to charges as determined. This document should remind patients they are responsible for knowing their benefits, and that they will be responsible for any insurance-allowed charges encountered, should the insurance not cover the charges.
6. If the individual insurance plan agreement allows, collect all copays before the patient begins the visit.
7. If, during the patient encounter, it is determined that further testing is needed, have your team notify the patient of the tests needed and the patient responsibility for the testing. Then, confirm that the patient consents to treatment and charges.
8. Put everything in writing. Insurance can be complicated for the patient to understand, and it is easier for everyone in the practice, including the patient, if a pre-populated form is used that delineates all the information outlined above. Fill in the blanks on the form with the exact amounts for each patient, have the patient sign the form, which will include any insurance-required statements, and keep a copy of this form as part of the patient record.
9. Post a sign that clearly states the practice’s refund policy, for example, “No refund.” The sign should also include that payment is to be made when the service is rendered.

TAKE ACTION ON ACCOUNTS RECEIVABLE

The following is a list of action steps you can take to decrease accounts receivable (AR).

• Verify all insurance, both medical and managed vision care plans, prior to the patient’s visit.
• Let patients know of costs before testing; collect all copays at the time of the visit.
• Self-audit claims.
• Send claims to insurance companies daily.
• Run AR reports weekly, and assign team members to act on the outstanding amounts.
• Follow up with outstanding accounts for both patients and third party payers. (I have found that being consistent with sending patients bills, once a week, is as effective as sending to collections agencies — and much kinder.)
• Review all insurance claims for opportunities to correct and resubmit and, if needed, call, and find out why old claims remain unpaid. Start with the past three months, and then go to a year.
• Look for claims never submitted, and resubmit before the time limit is up.
• Call patients about unclaimed and unpaid product; offer to ship to them, at no charge, if they pay their balance.

ADDITIONAL RESOURCES

There are many resources out there for assistance with billing and coding. Some of these are AOA, CMS, AAO, JHCAPO, CPT and AMA, in addition to state associations. To stay in the know, register for updates, and bookmark your favorite resources. The reason for all the interest in this topic is justified. This is an ever-changing area. Stay tuned to the “Coding Strategies” column and continue to send in questions (april.jasper@pentavisionmedia.com)! OM

DR. JASPER practices in West Palm Beach, Fla. She is an American Academy of Optometry fellow and is chief optometric editor of Optometric Management. Email her at april.jasper@pentavisionmedia.com.