What’s New on the Insurance Horizon?


Previously I wrote about our thinking in being non-par providers of vision therapy services.  When I first began addressing this years ago, I was somewhat of a Lone Ranger.  Progressively through the years more colleagues have begun to share my philosophy of maintaining the primary relationship with the patient rather than with the insurance carrier.  Let me show you an example of how we advocate for the patient being reimbursed to whatever extent they are entitled by their carrier.

The nice thing about being a non-par provider is that we can serve as a stronger advocate for the patient than if were were in the system.  We don’t have to worry about getting our wrist slapped for making waves.  Horizon Blue Cross/Blue Shield happens to be among the better carriers regarding VT reimbursement to the patient.  While HIPPA privacy prevents me from revealing our patient’s name, I’m delighted to share the name of Stanley Harris, M.D. with you.  I’m not sure who he is, or where he’s located, but as the Medical Director for Horizon BC/BS and a specialist in Pediatrics Dr. Harris gets it.  There are several key features to note:

1)As out-of-network providers, our fee for a 30 minute block of orthoptic VT (92065) falls within the usual and customary range for reimbursement.

2) The Medical Director acknowledges that the patient is able to be reimbursed for two consecutive units (60 minutes) of therapy on the same day.

3) Our fee for a sensorimotor progress evaluation (92060-76) falls within the usual and customary range for reimbursement.

Why is this important?  Because any time a patient does battle with their carrier over reimbursement, we arm them with whatever ammunition we can.  Sample approval letters like the one above, particularly when a patient is covered by the same carrier, are evidence that the treatment is medically necessary, not experimental or educational in nature, and falls within the usual and customary reimbursement range.

– Leonard J. Press, O.D., FCOVD, FAAO

4 thoughts on “What’s New on the Insurance Horizon?

  1. Len,
    Don’t your patients scream about the difference in their deductible because you are out-of-network? If you’re in-network their child’s deductible is $100. However, because you’re out-of-network, your patient must pay $2,000 before they really get any insurance benefit.

    I also have another question: who determined that 92065 was a 30 minute visit? The CPT does not provide a timeframe for this service. It seems to me that it could ‘theoretically’ be 5 minutes or 5 hours. It is very interesting to me that your request to have two 30 minute units in the same day was approved. I am hopeful that your experience (and your publishing this EOB) will help me with my fight with BCBS of NE.

    Thanks for sharing!
    Vicky

  2. You’re welcome, Vicky. My pleasure to share, and hope it can be of further help to you in NE. Regarding your two points:

    1) You misinterpreted the language regarding the $2000. Frankly without checking with my office manager, who has become a pro at dealing with insurance-speak, I wouldn’t have figured it out. The $2000 isn’t part of the previous sentence that refers to the deductible. It means that the proposed allowance of $125 per unit) is covered at the rate of 80% (i.e.$100) up to $2000. Once $2000 out-of-pocket has been paid to our office by the patient, they will be reimbursed in full (as we are not above the allowance).

    2) The fact that time isn’t built into 92065 means that there is wiggle room for the interpretation of how much time constitutes the session. For example, for a young child with a limited attention span, or a developmentally delayed child, 30 minutes might be a victory. As you know, OT/PT therapy codes, the 97000 line, which they use in 15 minutes of time. While either 5 mins or 5 hours could theoretically be used as a cluster or unit of time, 30 minutes has worked out very well as a reasonable unit for orthoptic VT. So years ago we decided that 30 minutes would be our unit of therapy. When a patient is capable of doing an hour, we bill it as 2 units. We’re very up front with both the patient and the carrier about this and it serves all parties well.

  3. Len, Thank you for this very clear statement about the benefits to the patient of being an independent provider, not affiliated with the insurer. In this economy, it is doubly important to do whatever is possible to enable the parent/patient to enroll in and complete therapy. Thomas Lecoq

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