Today I hear about an optometrist in Utah who bilked Medicaid for patients he never even saw!

Before insurance companies (especially government ones) start bearing down on all of us with burdensome regulations because of a few bad actors, let’s take a step back an look at the problem from a different angle.

This is why insurances shouldn’t pay for physician office visits, but if they want to, then leave the doctor out of it and just reimburse the patient. My car insurance doesn’t pay for oil changes or gasoline. If my car insurance was crazy enough to offer an oil change benefit, then that would be great, but if I’m Convenience Lube, then no way would I take deferred payment from some car insurance company. I would demand the car owner pay at the time of service, and their crazy insurance company can reimburse the car owner later. If my car is in a major accident, then I would less likely have cash on hand for an expensive repair, so this is when the insurance companies would step in. Besides, autobody shops are much more accustomed to dealing with insurance compared to oil change shops or gas stations.

This is how it should be in healthcare. Only certain providers would really have a need to regularly bill insurances. Mostly doctors doing surgeries, hospitals, or other high cost care environments.

Number one, this helps lower the cost of medical care because people find out how much it actually costs since doctors don’t have a big menu/price sign over the reception desk. Second, doctors don’t have to spend tons of money and time filing claims. Third, the incidence of doctors perpetrating insurance fraud would go down because doctors would have less opportunity anyway. Fourth, if something isn’t covered by insurance, who presently gets to eat it? Usually the doctor. Patients paying their own office visits would force the patient to be more accountable for whether they really want/need a particular service, regardless if they expect their insurance to reimburse or not.

The doctor shouldn’t be beholden to any insurance company. He should deliver care according to his training/experience. She shouldn’t have to try to remember that Insurance A will pay for a visual field once a year, but Insurance B will allow it twice a year, etc. He shouldn’t think about if he has the patient do an extended medical history, he can upgrade his exam from level 3 to level 4 to bilk the insurance company for all they’re worth because hey, the patient is only paying a copay, right?

I think big ticket items like billing for surgeries or expensive procedures should still be billed by providers/hospitals since this is what insurance is for: paying for catastrophic, unexpected events. But all the little stuff, like inpatient food service and routine exams and regular office visits should be paid up front by patients. It would lower healthcare costs because providers could lower prices since their labor and accounts receivable would decrease. It would decrease over-utilization since patients have a financial stake in the process. It would decrease fraud since there would be less opportunity to create fraud by the majority of doctors/patient encounters.

The procedure code is inconsistent with the provider type/specialty (taxonomy).

So I called Utah Medicaid, and confirmed that 92025 is the code for corneal topography, and they confirmed that optometrists are not allowed to be paid for corneal topography because only physicians and hospitals are allowed to bill this procedure code. I pressed that optometrists manage conditions like keratoconus with corneal topography and that their policy definitely needs to be changed. The UT medicaid worker said she would bring it up at their meeting, but that meeting isn’t until next week, and she had several other issues that weren’t address at the last meeting.

So, I think she was telling me that she couldn’t guarantee that anything regarding my issue would be addressed in the near future. Even if they do discuss it sometime this month, they might not change their mind.

THIS IS COMPLETELY RIDICULOUS!!!. Hospitals? Hospitals can bill for corneal topography? How often do they do that? Can we name even one hospital that even owns a corneal topographer? The only physicians who use corneal topographers are ophthalmologists, but if I were a pediatrician they would allow me to bill for it?

Attention Utah Medicaid Taxonomy-Procedure-Provider-Type Committee: I hereby declare that you should immediately allow optometrists, provider type 31, to bill and be reimbursed for computerized cornea topography, CPT code 92025. Blue Cross allows it. I am trained to perform and analyze this test in optometry school. I need it to manage conditions like keratoconus, irregular astigmatism, pterygium, pellucid marginal degeneration, and transplanted cornea. All of these conditions I see in my practice.

Until now, I am willing to grant that the taxonomy/provider-type thing is an oversight- a snafu with the computer database. Now that this error has come to light, the only reason I can think that Utah Medicaid would continue in this erroneous policy is that the committee members making that decision are a bunch of anti-optometrist bigots. I don’t want to think that, so please reverse your policy as quickly as possible and allow optometrists to bill corneal topography.

In the 2011 CPT Coding Manual, which is effective January 1, 2011, CPT code 92135 has been deleted and replaced with the following codes:

• 92132 – Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral (Replaces 0187T)
• 92133 – Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve
• 92134 – Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina

I like that because I hate having to remember modifiers like RT and LT, especially on tests that are most always run bilaterally anyway. I’m sure the insurance companies will like it for stats because it’s more descriptive by differentiating optic nerve vs. anterior segment vs. posterior segment.

UPDATE: Chuck Brownlow has more on this code change along with fiscal impacts.

The libertarian in me thinks that ideally I should be able to collect or not collect with impunity, but I was sure current contractual agreements with “private” insurers required that I always collect.

(Note: I put quotes around “private” insurance since Obamacare effectively takes the free out of free enterprise.)

Anyway, along comes progress. OM with release 9 has implemented the famous, awesome SQL database. What makes it famous and awesome is that SQL is opened source and cross platform. So of course OM implements a Microsoft only version of SQL. The Windows Server Small Business that I’ve been using isn’t supported, so now I am faced with paying a whole bunch of money for a new edition of Windows Server standard. If I upgrade to that, I might as well update my client machines to Windows7. If I do that, my current video cards don’t support it, so I’ll have to either buy new video cards or just a new box.

So now, with all that plus the yearly, over $1K fee for OM, I’m wondering if I shouldn’t start over with some other solution. To tell you the truth, the only thing I use OM for is electronic billing. I just scan my paper charts with my awesome and fast Fujitsu Fi-6130 document scanner.

I really wish OfficeMate would have implemented a cross platform implementation of an SQL db. I could have just used a free Linux server to host the db.

Eye Exam Types

For more interesting stats to help you make your business plan, the OBA-CE has compiled these:

• Revenue Per Exam
• Complete Exams per OD Hour
• Annual Revenue Growth Rate
• Internet Site Penetration
• Contact Lens Usage by Lens Type
• Recall System Independent of Vision Center
• Walk-in Ratio
• Contact Lens Exams Percent of Total Exams
• Medical Eye Care Visits as Percent of Total Visits
• Exams Percent of Active Patients
• Professional Fee Income Percent of Total Location Revenue
• Performance Metrics by Years at Location
• "Elite” Practice Metrics
• Performance Metrics for Walmart and Sam’s Club Locations

Beginning April 15, 2010, PEHP will no longer reimburse consultation codes. Providers will need to bill the appropriate Evaluation and Management code for the visit.

I’ve probably never had to bill a consultation code, but I imagine ophthalmologists won’t be too happy with this change.

I wonder how long it will be until every insurance company finds out that private pay individuals rarely get billed the higher fee consultation codes…

Thus, I think a term that I would like to propose for use in further discussions of newer ways of practicing primary care is “insurance free medicine.” The term “insurance free medicine” captures the essence of the newer models of primary care. Patients have certainly seen their premiums and deductibles increase and can probably relate quite well to reasons why a doctor would not accept insurance.

Insurance free primary care practices could certainly adopt retainer membership fees and promote improved access, but eliminating terms like “boutique,” “concierge,” and “cash only” might help eliminate the notion that primary medical care without insurance is somehow tainted or only for the super-wealthy. Previously, I discussed that without substantial changes, primary care will soon go the way of psychiatry in that patients who use their insurance to see a psychiatrist get one kind of care (very brief visits, mostly management by a non-physician) and those who pay their psychiatrist out-of-pocket get the kind of care that we see in TV and the movies.

With more frequent use of the term “insurance free medicine,” patients might start realizing that if they continue to pay their primary physician using their health care insurance, they should expect even briefer visits, longer waits to get in, seeing non-physicians, and greater delays getting a return phone call or results back.

I calculated the other day that I spent about $2000 a year to be set up and able to bill insurance. Further, I spent all that time and money for about 538 patients, or close to one-fourth of my patients per year. Now that Walmart no longer bills many vision plans for me, both numbers will go up, and so will my accounts receivable. In anticipation of this, my fee went up by $5 per patient at the beginning of the year.

I would lower my price if we could all convince the general public that routine medical office visits should be paid out of pocket. Your car insurance doesn’t pay for oil changes.

The not so simple question...

There is a not-so-simple question that pretty much every patient asks, “How much is your eye exam.”

While the medical model has varying levels of exam, like Level II-New vs. Level IV-Est, which depend upon the history, exam, and complexity of that particular case; however, there are some among our profession that make it an especially hard question to answer, and this issue raises concern over the ethics of a fairly popular fee structure.

For example: the price in front of the Big Box says “Eye exams starting at $45!”
But are they really? Sure, for a “routine eye exam” where nothing is wrong and you just want your glasses updated, then it’s the $45. But what if I have some allergy eyes, so the doctor gives me a prescription for Pataday as well as my glasses Rx? All the sudden the exam somehow costs $120!?!?

Huh, something funny going on around here. I think big box doctors are more likely to do this since their exam fees are so low, they make up for it by gouging in other fees. I have no problem with a doctor who says their S0620 is $100 and their 92004 is $120. However, I think there is something wrong if the S0620 is $45 and the 92004 is $140.

It’s like some among us in the optometric profession are playing the windshield chip repairman scheme.

But what really happens? Patients won’t typically notice this bait-and-switch. It’s really the insurance companies who get hammered. The patient pays their copay, and if the doctor can come up with any excuse to bill a medical code, they use their medical model fee structure to justify it.

Ethics applies when we realize that, for some reason, private pay patients are rarely charged the same high fees as the insurance companies. Huh. Oh well. It’s a victimless crime because those big, bad insurance companies won’t miss the extra cash. Until we realize that the more insurance companies pay out, the more the patient’s premiums will be raised next year. Whoops. Sorry, Mrs. Smith, that you can’t afford to keep your medical insurance in the future because I wanted to get paid double or triple my usual fee because you have insurance today.

By the way, it cost me about $2000 to bill insurance last year (PIM software license, E-filing charges, and postage/paper for mailing statements/refunds). Also add to that the cost of time spent filing claims and handling overpayment and underpayment. If I didn’t have to deal with insurance, I could drop my exam fee by at least $5 per person.

I have an idea: All patients should pay for office visits out of pocket. If they have insurance, get reimbursed later. The doctor won’t know about their insurance, so there won’t be a conflict of interest about what exam fee structure he’ll choose. The doctor can lower his fees since filing claims is expensive and time consuming. Everyone wins. Another idea, insurances should allow me to charge either them or the patient a $5 claim filing service fee.

Take home point: I don’t believe it is ethical to have one fee structure for insurance patients and another drastically different one for private pay. Yes, I’m all for charging more money if something is more work and more time. That’s why a contact lens evaluation is paid on top of the routine eye exam. That’s why there are different levels of 99*** office visits. But sneaking a huge fee onto an insurance claim just because there is some medical code excuse is something I don’t think our profession should feel comfortable with.

Yup, I’ve said it before and I’ll say it again. Ophthalmic vendors think we optometrists are so stupid. Just because we picked this profession, they think we are prone to making poor financial choices just like some people are accident prone.

Any of you vendors seeking to do insurance billing for me are wasting your time. All I need is my practice management software and Apex EDI. It’s as automated as can be. Most of the vision insurances have their own website for authorization and billing, and then I use Apex EDI for my BlueCross, Medicaid, DMBA, and other miscellaneous insurance companies. (You can do Medicare also, but I am disinclined to participate with them.)

Apex EDI works great. It’s fast and easy. And I don’t need no stinking slick Rick to be some unnecessary middle man. It’s cheap too. I pay 43 cents per claim, less than a postage stamp these days. I also pay the extra $20 a month for the ERAs and Electronic Tools which make my life a lot easier, so it’s worth it.

Call up Apex EDI and tell them I sent you. Use my Champions Code (sales code) to get a better deal: Champ148. I use it in my practice (VisionHealth EyeCare PLLC), and you can use it in yours without the growing cottage cheese industry of Walmart insurance billing middle men.

[Note to Slick Ricks: Any more "comments" made by you to advertise your middle man services will be marked as Spam and deleted. Do us all a favor and go con some other profession.]