Contact Lens Spectrum Supplements

Special Edition 2017

Contact Lens Spectrum

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c l s p e c t r u m . c o m C O N T A C T L E N S S P E C T R U M S P E C I A L E D I T I O N 2 0 1 7 59 testing, and lenses, are included in the MNCL benefits. Any medical problem that develops within this period, but outside the contact lens process (e.g., corneal abra- sion, subconjunctival hemorrhage, corneal ulcer, etc.), is billed to medical insurance. Likewise, any care provided outside of the 90-day window but associated with the MNCLs should be billed to medical insurers. For many practitioners, this process is new. The vision- defined section of the Affordable Care Act adopted this bundling model, in part, because of negotiations with the American Optometric Association (AOA). Previ- ously, the rules for MNCLs were not clearly defined by the vision insurers. Practitioners ended up interpreting the rules themselves and often failed audits as a conse- quence. High utilizers of medically necessary benefits were confronted with recovery audits to find errors in interpreting the rules from the perspective of the payers. They had extrapolated penalties assessed (sometimes six figures) that in some cases were practice killers. Two of the chief negotiators from the AOA, Clarke D. Newman, OD, Dallas, and Stephen M. Montaquila, Warwick, R.I., went to the bargaining table with one of the vision insur- ers and helped create a system that was fair to all parties. The other major vision insurer recently followed suit and instituted a 90-day global period. The concept of 90 days of covered services has an im- portant consequence for your practice. To continue pro- viding the service while remaining profitable, practitio- ners must achieve the maximum success in a reasonable number of office visits. If a patient's stage of disease calls for simpler lenses, such as a custom soft toric or a vaulting hybrid that can be fit in fewer visits than a scleral lens, those options should not be overlooked. Office visits must be managed properly to avoid disrupt- ing other aspects of the practice. Patients who need MN- CLs require substantially more chair time than patients who need general or medical care, and scheduling must account for these differences. Determining how to man- age visits depends on the number of MNCL patients the doctor sees. In our practice, most patients require MN- CLs, so we book on the half hour with high technician coverage. If your practice has a more varied patient popu- Finally, reflecting on this negative experience, Dr. Doogood decides that treating patients with kera- toconus is not worth the cost of angering other patients when the clinic is delayed and not worth the frustration he experienced in the previous situation. During each of those return visits, Dr. Doogood was unable to see a pa- tient with uncomplicated needs, therefore losing revenue for his professional services and potentially losing sales from the purchase of eyeglasses and contact lenses in his optical department. As a result of this one experience, Dr. Doogood stops managing patients who have keratoco- nus. This is in no one's best interest. WHAT SHOULD HAVE HAPPENED If Dr. Doogood had billed appropriately for his services and educated the patient about what to expect, everyone would have benefited. Dr. Doogood would have used Eyemed's medically necessary benefit procedure and included the cost of return visits in his evaluation fee, thus avoiding mounting frustration with each additional visit. The patient would have been informed initially that advanced contact lenses often require multiple office visits. Dr. Doogood would have explained that there are many options in contact lenses for patients with keratoconus, and that he was going to start with the simplest lenses and progress to more complex lenses, if indicated. Dr. Doogood and the patient would have been on the same page and worked as partners through the process until they achieved an acceptable outcome. There are multiple methods for billing and coding for specialty custom contact lenses. The rules differ based on whether you're filing a claim with vision insurers or medical insurers. Errors may cause serious consequenc- es, including audit failure, recovery of reimbursements, removal from panels, civil litigation, and in the case of government payers, criminal prosecution. The information presented here is based on years of filing medical and vision benefit claims for medically necessary contact lenses, successful audits from multiple insurers, and working directly with medical directors or medical advisory board members within various insurers. VISION INSURANCE Most vision insurance or vision care plans have a provi- sion for medically necessary contact lenses (MNCLs) and should be considered primary when the patient has vision and medical benefits and the doctor is on both panels. Vision insurers share one common feature for medically necessary benefits: bundling. Vision plans pay the provid- er for the procedure codes used regardless of the number of visits required to complete the process. The top two plans by numbers of subscribers are Eyemed and VSP, and they will be discussed individually later. In both plans, 90 days of services, including visits, CODING Y o u a n d y o u r s t a f f m u s t un d e r st an d h o w t o b i l l a n d c od e p r o p e r l y f o r t h i s s p e c ia l i z e d c a r e .

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