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1 Should I Become a 3 rd Party Provider Addressing: The types of 3 rd Party Payers The types of 3 rd Party Payers Why or why not be a 3 rd Party Provider.

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Presentation on theme: "1 Should I Become a 3 rd Party Provider Addressing: The types of 3 rd Party Payers The types of 3 rd Party Payers Why or why not be a 3 rd Party Provider."— Presentation transcript:

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2 1 Should I Become a 3 rd Party Provider Addressing: The types of 3 rd Party Payers The types of 3 rd Party Payers Why or why not be a 3 rd Party Provider Why or why not be a 3 rd Party Provider

3 2 Disclaimers 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.

4 3 Disclaimer 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.

5 4 Types of 3 rd 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 3 rd party Combo: Routine & Medical by same 3 rd party

6 5 Types of 3 rd Party Payers Routine (pre-paid) Care Routine (pre-paid) Care Cover Exam and materials Cover Exam and materials Limits on frequency Limits on frequency Limits on materials Limits on materials Does not pay for medical services (fields, gonioscopy, retinal photos) Does not pay for medical services (fields, gonioscopy, retinal photos) Generally file over Internet or may use own claim forms Generally file over Internet or may use own claim forms

7 6 Types of 3 rd Party Payers Routine examples: Routine examples: – VSP – EyeMed (Eye Care Plan of America) – Optum Health (Spectera) – Medicaid ( patients w/o medical diagnosis )

8 7 Types of 3 rd Party Payers Medical (health insurance coverage of eye Dx) Medical (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 materials Rarely pays for materials File electronically using HIPAA approved format (5010 electronic claim format soon required), or File electronically using HIPAA approved format (5010 electronic claim format soon required), or File on paper CMS-1500 forms File on paper CMS-1500 forms Only okay if less than 10 FTE employees Only okay if less than 10 FTE employees 5010 format coming up 5010 format coming up

9 8 Types of 3 rd Party Payers Medical examples Medical examples – Blue Cross Blue Shield – Coventry – United Health Care – Medicare – Medicaid medical coverage

10 9 Types of 3 rd Party Payers Combination of Routine & Medical coverage Combination of Routine & Medical coverage If no medical diagnosis, routine care limitations apply If no medical diagnosis, routine care limitations apply If medical diagnosis only, medical insurance limitations apply If medical diagnosis only, medical insurance limitations apply If both refractive and medical services are provided, respective limitations apply. (varies, however) If both refractive and medical services are provided, respective limitations apply. (varies, however)

11 10 Types of 3 rd Party Payers Combination Examples Combination Examples – Conventional Medicaid (Over 65 y.o. or nursing home) – Optum Health (Spectera) Routine w/ United Health Care medical – BCBS medical w/ EYEMED routine – VSP routine w/ either CIGNA or BCBS medical – BCBS special policies that include routine care

12 11 Should You Become a Provider? Don’t have to be provider; rather can… Don’t have to be provider; rather can… Give Patient “super-bill” or a printed claim form Give Patient “super-bill” or a printed claim form Patient pays your fee to you Patient pays your fee to you Patient sends claim to Insurer Patient sends claim to Insurer Insurer pays patient their allowable Insurer pays patient their allowable –Exception: Medicare  If you see a Medicare patient, you must file the claim for the patient.

13 12 Should You Become a Provider? Thus, the advantages of not being provider: Full fee Full fee  (Medicare has fee limitations on non-providers) Don’t file claims Don’t file claims  (Must file Medicare) No limit on services provided No limit on services provided  (except Medicare)

14 13 None –Provider: Accepting Assignment If you are not a provider for an insurer, but, as a courtesy, you decide to file the claim for the patient, you have the choice of whether to Accept Assignment If you are not a provider for an insurer, but, as a courtesy, you decide to file the claim for the patient, you have the choice of whether to Accept Assignment If you Accept Assignment, you agree to accept what an insurer pays, and the insurer pays you directly. If you Accept Assignment, you agree to accept what an insurer pays, and the insurer pays you directly. If you do not Accept Assignment, the insurance payment goes to the patient, and the patient (hopefully) pays you. If you do not Accept Assignment, the insurance payment goes to the patient, and the patient (hopefully) pays you. as an aside

15 14 Should You Become a Provider? Advantages of being a provider On provider list (strong patient resource) On provider list (strong patient resource) Fewer $ collection problems Fewer $ collection problems Patient happy Patient happy  Doesn’t have to file own claim  Less $ out-of pocket  Fees seem more reasonable than out-of-plan provider’s fees

16 15 Should You Become a Provider? If you have signed up to be a provider for a private insurer, you have agreed to accept what they pay, and payments will come directly to you. you have agreed to accept what they pay, and payments will come directly to you. You can only bill the patient for deductible and co-pay. You cannot “balance bill” for the rest of your fee. You can only bill the patient for deductible and co-pay. You cannot “balance bill” for the rest of your fee.

17 16 Should You Become a MEDICARE Provider? If you see ANY Medicare patients, you must follow ALL Medicare rules. If you see ANY Medicare patients, you must follow ALL Medicare rules. You have a choice of Participating or not Participating Medicare Provider. You have a choice of Participating or not Participating Medicare Provider.

18 17 Participating Providers are paid directly by Medicare using their “Par” fee schedule Participating Providers are paid directly by Medicare using their “Par” fee schedule None-Participating Providers… None-Participating Providers… Medicare will pay the patient Medicare will pay the patient The patient will (hopefully) pay you. The patient will (hopefully) pay you. What you charge a Medicare patient is limited by Medicare’s “limiting charge”. You cannot bill beyond the limiting charge. What you charge a Medicare patient is limited by Medicare’s “limiting charge”. You cannot bill beyond the limiting charge. Should You Become a MEDICARE Provider?

19 18 Should You Become a MEDICARE Provider?

20 19 Medicare Advantage (MA) Medicare Advantage (MA) Privatization of Medicare Privatization of Medicare Medicare charges patient then pays insurance companies a capitation amount per patient Medicare charges patient then pays insurance companies a capitation amount per patient Claims are filed with these MA companies, not with traditional Medicare Claims are filed with these MA companies, not with traditional Medicare Many patients do not understand they are no longer covered directly by Medicare Many patients do not understand they are no longer covered directly by Medicare Should You Become a MEDICARE ADVANTAGE Provider?

21 20 Medicare Advantage Medicare Advantage Cost to patient may be the same as for traditional Medicare, or there may be an additional charge over traditional Medicare Cost to patient may be the same as for traditional Medicare, or there may be an additional charge over traditional Medicare MA policies may have different co-pay amounts and deductibles than traditional Medicare MA policies may have different co-pay amounts and deductibles than traditional Medicare Some plans offer additional benefits (dental care, routine vision, drug coverage included) Some plans offer additional benefits (dental care, routine vision, drug coverage included) Should You Become a MEDICARE ADVANTAGE Provider?

22 21 Medicare Advantage comes in a variety of types Medicare Advantage comes in a variety of types HMO: Patients see only HMO panel doctors; panel networks small; providers accept HMO’s fees HMO: Patients see only HMO panel doctors; panel networks small; providers accept HMO’s fees PPO: Panels more open; some out of panel coverage; providers agree to accept PPO fees PPO: Panels more open; some out of panel coverage; providers agree to accept PPO fees PFFS (Private Fee For Service)…next slide PFFS (Private Fee For Service)…next slide Should You Become a MEDICARE ADVANTAGE Provider?

23 22 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 network Provider does not sign up to be in network If you accept a PFFS MA patient, you are “deemed” to accept their fee schedule. If you accept a PFFS MA patient, you are “deemed” to accept their fee schedule. If in doubt, check on reimbursement before seeing patient. If in doubt, check on reimbursement before seeing patient. Should You Become a MEDICARE ADVANTAGE Provider?

24 23 A list of the Medicare Advantage plans found in Nebraska can be found at the Nebraska SHIIP web site, A list of the Medicare Advantage plans found in Nebraska can be found at the Nebraska SHIIP web site, Should You Become a MEDICARE ADVANTAGE Provider?

25 24 Thank You for Listening We hope this information has been helpful. Thank you for listening! See our NOA Website for more 3 rd Party Educational Videos. 3 rd Party Services Nebraska Optometric Association


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