1 should i become a 3 rd party provider addressing: the types of 3 rd party payers the types of 3 rd...

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Should I Become a Should I Become a 33rdrd Party Provider Party Provider

Addressing:Addressing:• The types of 3The types of 3rdrd Party Payers Party Payers• Why or why not be a 3Why or why not be a 3rdrd Party Party ProviderProvider

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DisclaimersDisclaimers

This information was prepared by the 3rd Party Consultant to the Nebraska Optometric Association, Ed Schneider OD.

To the best of his knowledge, it was current and accurate at the time it was prepared. It is not guaranteed to be error or omission free.

It was prepared as general information to assist doctors and staff, and is not intended to grant rights or impose obligations.

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DisclaimerDisclaimer

• The ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services.• The Nebraska Optometric Association, and its presenters, agents, consultants and staff make no representation, warranty, or guarantee that this presentation and/or its contents are error-free or omission-free, and will bear no responsibility or liability for the results or consequences of the information contained herein.

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Types of 3Types of 3rdrd Party Payers Party Payers

Routine Vision Care (prepaid care)Routine Vision Care (prepaid care) Medical (health insurance coverage)Medical (health insurance coverage) Combo: Routine & Medical by same 3Combo: Routine & Medical by same 3rdrd

party party

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Routine Routine (pre-paid) Care(pre-paid) Care• Cover Exam and materialsCover Exam and materials• Limits on frequency Limits on frequency • Limits on materialsLimits on materials• Does not pay for medical services (fields, Does not pay for medical services (fields,

gonioscopy, retinal photos)gonioscopy, retinal photos)• Generally file over Internet or may use own Generally file over Internet or may use own

claim formsclaim forms

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• Routine examples:Routine examples:– VSPVSP– EyeMed (Eye Care Plan of America)EyeMed (Eye Care Plan of America)– Optum Health (Spectera)Optum Health (Spectera)– Medicaid (Medicaid (patients w/o medical diagnosispatients w/o medical diagnosis))

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MedicalMedical (health insurance coverage of eye Dx) (health insurance coverage of eye Dx)• Medical diagnosis only (not refractive codes)Medical diagnosis only (not refractive codes)• Pays for other medical services (fields, photos)Pays for other medical services (fields, photos)• Rarely pays for materialsRarely pays for materials• File electronically using HIPAA approved format File electronically using HIPAA approved format

(5010 electronic claim format soon required), or (5010 electronic claim format soon required), or • File on paper CMS-1500 formsFile on paper CMS-1500 forms

• Only okay if less than 10 FTE employees Only okay if less than 10 FTE employees • 5010 format coming up5010 format coming up

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• Medical examplesMedical examples – Blue Cross Blue ShieldBlue Cross Blue Shield– CoventryCoventry– United Health CareUnited Health Care– MedicareMedicare– Medicaid medical coverageMedicaid medical coverage

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Combination of Routine & Medical Combination of Routine & Medical coverage coverage

• If no medical diagnosis, routine care limitations If no medical diagnosis, routine care limitations applyapply

• If medical diagnosis only, medical insurance If medical diagnosis only, medical insurance limitations applylimitations apply

• If both refractive and medical services are If both refractive and medical services are provided, respective limitations apply. (varies, provided, respective limitations apply. (varies, however)however)

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• Combination ExamplesCombination Examples– Conventional Medicaid (Over 65 y.o. or nursing Conventional Medicaid (Over 65 y.o. or nursing

home)home)– Optum Health (Spectera) Routine w/ United Optum Health (Spectera) Routine w/ United

Health Care medicalHealth Care medical

– BCBS medical w/ EYEMED routineBCBS medical w/ EYEMED routine– VSP routine w/ either CIGNA or BCBS medicalVSP routine w/ either CIGNA or BCBS medical– BCBS special policies that include routine careBCBS special policies that include routine care

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Should You Become a Should You Become a Provider?Provider?

Don’t Don’t havehave to be provider; rather to be provider; rather can…can…• Give Patient “super-bill” or a printed Give Patient “super-bill” or a printed

claim formclaim form• Patient pays your fee to youPatient pays your fee to you• Patient sends claim to InsurerPatient sends claim to Insurer• Insurer pays patient their allowableInsurer pays patient their allowable– Exception: MedicareException: Medicare

If you see a Medicare patient, you must file If you see a Medicare patient, you must file the claim for the patient.the claim for the patient.

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Thus, the advantages of Thus, the advantages of notnot being being provider:provider:

Full feeFull fee (Medicare has fee limitations on non-(Medicare has fee limitations on non-

providers)providers) Don’t file claims Don’t file claims

(Must file Medicare)(Must file Medicare)

No limit on services provided No limit on services provided (except Medicare)(except Medicare)

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None –Provider:None –Provider:Accepting AssignmentAccepting Assignment

If you are If you are notnot a provider for an insurer, but, as a provider for an insurer, but, as a courtesy, you a courtesy, you decide to file the claimdecide to file the claim for the for the patientpatient, you have the choice of, you have the choice of whether towhether to Accept AssignmentAccept Assignment • If you If you Accept AssignmentAccept Assignment, you agree to accept what an , you agree to accept what an

insurer pays, and the insurer pays you directly.insurer pays, and the insurer pays you directly.• If you If you do not Accept Assignmentdo not Accept Assignment, the insurance payment goes , the insurance payment goes

to the patient, and the patient (hopefully) pays you. to the patient, and the patient (hopefully) pays you.

as an aside

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Advantages of Advantages of beingbeing a provider a provider On provider list (strong patient resource)On provider list (strong patient resource) Fewer $ collection problemsFewer $ collection problems Patient happy Patient happy

Doesn’t have to file own claimDoesn’t have to file own claim Less $ out-of pocket Less $ out-of pocket Fees seem more reasonable than out-of-plan Fees seem more reasonable than out-of-plan

provider’s feesprovider’s fees

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If you have signed up to be a provider for If you have signed up to be a provider for a private insurer, a private insurer,

you have agreed to accept what they you have agreed to accept what they pay, and payments will come directly to pay, and payments will come directly to you.you.

You can only bill the patient for You can only bill the patient for deductible and co-pay. You cannot deductible and co-pay. You cannot “balance bill” for the rest of your fee.“balance bill” for the rest of your fee.

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Should You Become a Should You Become a MEDICARE Provider?MEDICARE Provider?

If you see ANY Medicare patients, you If you see ANY Medicare patients, you must follow ALL Medicare rules.must follow ALL Medicare rules.

You have a choice of You have a choice of ParticipatingParticipating or or not not ParticipatingParticipating Medicare Provider. Medicare Provider.

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ParticipatingParticipating Providers are paid directly Providers are paid directly by Medicare using their “Par” fee by Medicare using their “Par” fee scheduleschedule

None-ParticipatingNone-Participating Providers…Providers… • Medicare will pay the patientMedicare will pay the patient• The patient will (hopefully) pay you.The patient will (hopefully) pay you.• What you charge a Medicare patient What you charge a Medicare patient is is

limited by Medicare’s “limiting charge”. You limited by Medicare’s “limiting charge”. You cannot bill beyond the limiting charge. cannot bill beyond the limiting charge.

http://www.wpsmedicare.com/j5macpartb/fees/general_fee_info/b_limiting.shthttp://www.wpsmedicare.com/j5macpartb/fees/general_fee_info/b_limiting.shtmlml


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Medicare Advantage (MA)Medicare Advantage (MA)• Privatization of Medicare Privatization of Medicare • Medicare charges patient then pays insurance Medicare charges patient then pays insurance

companies a capitation amount per patient companies a capitation amount per patient • Claims are filed with these MA companies, not Claims are filed with these MA companies, not

with traditional Medicarewith traditional Medicare• Many patients do not understand they are no Many patients do not understand they are no

longer covered directly by Medicarelonger covered directly by Medicare

Should You Become a Should You Become a MEDICARE ADVANTAGE MEDICARE ADVANTAGE

Provider?Provider?

2020

Medicare AdvantageMedicare Advantage• Cost to patient may be the same as for Cost to patient may be the same as for

traditional Medicare, or there may be an traditional Medicare, or there may be an additional charge over traditional Medicareadditional charge over traditional Medicare

• MA policies may have different co-pay MA policies may have different co-pay amounts and deductibles than traditional amounts and deductibles than traditional MedicareMedicare

• Some plans offer additional benefits (dental Some plans offer additional benefits (dental care, routine vision, drug coverage care, routine vision, drug coverage included)included)


Provider?Provider?

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Medicare Advantage comes in a Medicare Advantage comes in a variety of typesvariety of types• HMOHMO: : Patients see only HMO panel doctors; Patients see only HMO panel doctors;

panel networks small; providers accept HMO’s panel networks small; providers accept HMO’s feesfees

• PPOPPO: : Panels more open; some out of panel Panels more open; some out of panel coverage; providers agree to accept PPO feescoverage; providers agree to accept PPO fees

• PFFSPFFS (Private Fee For Service)…next (Private Fee For Service)…next slideslide


Provider?Provider?

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PFFS (Private Fee For Service): PFFS (Private Fee For Service): • No networks, No networks, • More expensive to patients, More expensive to patients, • Pays provider per its fee schedule, Pays provider per its fee schedule, • Provider does not sign up to be in networkProvider does not sign up to be in network• If you accept a PFFS MA patient, you are If you accept a PFFS MA patient, you are

“deemed” to accept their fee schedule.“deemed” to accept their fee schedule.• If in doubt, check on reimbursement before If in doubt, check on reimbursement before

seeing patient.seeing patient.


Provider?Provider?

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A list of the Medicare Advantage plans A list of the Medicare Advantage plans found in Nebraska can be found at the found in Nebraska can be found at the Nebraska SHIIP web site,Nebraska SHIIP web site, http://http://www.doi.ne.gov/shiip/medsup/medadv.pdfwww.doi.ne.gov/shiip/medsup/medadv.pdf


Provider?Provider?

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Thank You for ListeningThank You for Listening

We hope this information has been We hope this information has been helpful.helpful.

Thank you for listening!Thank you for listening!

See our NOA Website for more 3See our NOA Website for more 3rdrd Party Educational Videos.Party Educational Videos.

33rdrd Party Services Party Services

Nebraska Optometric AssociationNebraska Optometric Association

1 should i become a 3 rd party provider addressing: the types of 3 rd party payers the types of 3 rd...

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