Testing without charging

[kwr7126]

I'm wondering how many of you do any ancillary testing in your practices without billing and if you do, how often. I have previously done refractions for the sake of knowing BCVA and not charged the patient if they weren't interested in glasses. I get topography and OCT of the macula on premium lens patients and don't charge separately as I see it as part of the package. Finally, I occasionally order an OCT mac when the vision is worse than I would expect based on exam or when I'm uncertain about subtle macular pathology thru a cataract. I haven't felt right charging patients if turns out to be a normal test and I can't find a diagnosis for a billable code. My coding department is now requiring me to bill for any test I order and it's the patients problem if insurance doesn't cover it. They're telling me that it's not legal to do any sort of free testing. I was unaware of this. I bill for the vast majority of testing I order but I hate to lose the option of the occasional pre-phaco CYA OCT without patients having to pay cash and thinking I'm doing unnecessary tests just to make money. I'm open to the idea that this is just my crutch and I need to get over it but I would love to hear what the rest of you are doing. Thanks in advance!

---

Members don't see this ad.

 

[long]

I could be wrong, but the line that it's not legal to do a test without billing sounds like total BS. You can provide whatever medical services you want for free to your patients.


Sent from my iPhone using SDN mobile

 

[kwr7126]

That was my thought as well! I asked the head of our department. When he agreed with the coder, adding that you're no longer allowed to see other physicians for free I started questioning myself. Then again, the coder has probably been his source of billing information for decades... It sounds much more like a hospital administration line than a medicare rule to me.

 

[MullerCell]

If you don't have a billable diagnosis, then there is no medical necessity and claim will be denied anyway, so you have to no charge in that instance. I think it is wise to get an OCT on every pre-op cataract patient. If they have a subtle ERM, VMT, or other pathology that you notice after surgery when they can't get better than 20/40 they will blame your surgery even if it was perfect.

 

[KHE]

I don't think your biller is correct.

My understanding is that it is only illegal to not charge if the reason for not charging is to induce the patient into obtaining other services. For example...I won't charge you for the refraction if you get your cataract surgery from me.

-or-

You charge some benefit plans and not others. For example....blue cross pays you for the procedure so you charge them but Medicare doesn't so you just waive the fee for Medicare recipients.

If you want to do a test for your own benefit or interest and not that of the patient, the my understanding is that it's totally fine. Sometimes a patient might have a cool looking but totally benign or stable retinal lesion and I'll take a photograph of it because I like it. I won't charge for it because it doesn't aid in the management of the case but I want the photo for my own reason.

 

[kwr7126]

If you don't have a billable diagnosis, then there is no medical necessity and claim will be denied anyway, so you have to no charge in that instance. I think it is wise to get an OCT on every pre-op cataract patient. If they have a subtle ERM, VMT, or other pathology that you notice after surgery when they can't get better than 20/40 they will blame your surgery even if it was perfect.

Thanks for the input. Are you routinely doing OCTs on all your cataract preops? No issues? Unfortunately, the third option here is to have the patient sign an ABN, bill the OCT and when the claim is denied let the hospital send the patient a bill. That's what they're suggesting I do and I'm not a fan. Interestingly, I have a patient who is mad at one of my partners for the exact reason you stated. He did her first eye and I did the second. Both eyes ended up 20/30 with an ERM. She thinks I walk on water and thinks he "made a mistake." He's probably the better surgeon. The only difference was the preop discussion of her retina. In my mind the $30 technical fee is a small cost to pay for happy cataract patients.

 

[kwr7126]

I don't think your biller is correct.

My understanding is that it is only illegal to not charge if the reason for not charging is to induce the patient into obtaining other services. For example...I won't charge you for the refraction if you get your cataract surgery from me.

-or-

You charge some benefit plans and not others. For example....blue cross pays you for the procedure so you charge them but Medicare doesn't so you just waive the fee for Medicare recipients.

If you want to do a test for your own benefit or interest and not that of the patient, the my understanding is that it's totally fine. Sometimes a patient might have a cool looking but totally benign or stable retinal lesion and I'll take a photograph of it because I like it. I won't charge for it because it doesn't aid in the management of the case but I want the photo for my own reason.

Interesting. That makes a lot of sense. What about refractions on patients with separate vision insurance plans? We run into problems with patients who have health insurance that we accept and vision insurance that we don't accept. They still insist on seeing us when they have problems because we're in the same building as their PCPs and we're available 24-7. So they come to me with something like a lid lesion or iritis and are 20/50 phni. I feel like I should do a rough refraction so I'm not just sending them out with unexplained poor vision. I end up not charging them because they get mad at me if they get a bill because their optom refracted them 6 months before. Sounds like it actually might be a problem no charge these?

 

[KHE]

Interesting. That makes a lot of sense. What about refractions on patients with separate vision insurance plans? We run into problems with patients who have health insurance that we accept and vision insurance that we don't accept. They still insist on seeing us when they have problems because we're in the same building as their PCPs and we're available 24-7. So they come to me with something like a lid lesion or iritis and are 20/50 phni. I feel like I should do a rough refraction so I'm not just sending them out with unexplained poor vision. I end up not charging them because they get mad at me if they get a bill because their optom refracted them 6 months before. Sounds like it actually might be a problem no charge these?

Well, I guess two things on that....

1) If you have someone who's PHNI, then it would seem to me to be very UNlikely that an uncorrected refractive error is contributing in any meaningful way to the reduced vision which sort of negates the need to do the refraction in the first place.

2) I'm not sure what a "rough" refraction is but if you charge say $50 for a "thorough" refraction then it stands to reason that you should charge something less, perhaps even nothing for a "rough" one. If you're going to charge, you should do what you normally do, presumably the thorough one.

If the patient has a separate plan that covers the refraction and you don't participate then I guess the choice for the patient is to pay you and get it done or see the other provider and get it done.

 

[kwr7126]

Well, I guess two things on that....

1) If you have someone who's PHNI, then it would seem to me to be very UNlikely that an uncorrected refractive error is contributing in any meaningful way to the reduced vision which sort of negates the need to do the refraction in the first place.

2) I'm not sure what a "rough" refraction is but if you charge say $50 for a "thorough" refraction then it stands to reason that you should charge something less, perhaps even nothing for a "rough" one. If you're going to charge, you should do what you normally do, presumably the thorough one.

If the patient has a separate plan that covers the refraction and you don't participate then I guess the choice for the patient is to pay you and get it done or see the other provider and get it done.

Yeah, theoretically phni would suggest that refractive error wasn't contributing, but on a new patient you'd still check it, right? If there's no other obvious cause of decreased vision you're not going to do a whole workup without refracting just because they don't improve with pinholes. I have a subset of patients who can't figure out pinholes. They claim they can't see anything, you ask them to move the occluder around until they can see something, they claim they can't even see the big E, then they refract better. I realize it doesn't make sense from an optics standpoint. It didn't happen nearly as often with my former patient population. I have no good explanation except that I think there's some cultural component. Or it's my tech and I need to start checking VAs myself more often. Regardless, sometimes it's just easier to refract than push the pinholes. I have the same issue if they're 20/400 ph 20/50. I don't like to assume that it's limitation of the pinholes and they'd be 20/20 with refraction. I make sure they're correctable to close to 20/20 and if not I recommend we figure out why.

When I say "rough refraction" I mean I'm doing it pretty quickly with no intention of actually prescribing it. Basically I just want to make sure they're able to see, partly for my own medicolegal protection. If I put up -3.00 sph and they read 20/20-2 I don't tinker with the cyl if I'm doing it for free and they're not going to use the prescription. If they want new glasses I'll absolutely go thru the whole process to get them the sharpest vision possible. If I'm trying to document good BCVA to avoid being the guy who treated a chalazion and missed worsening ocular pathology then those 2 extra letters don't really matter. I've always thought of it as more of an extension of checking VA than as a separate service so I haven't charged. Again, it's not every patient or even every week but if doing it is actually illegal I have a bit of a problem on my hands because I don't feel good about sending people out of my office with decreased vision and no identified cause. I have definitely suggested that we either start taking the insurance or stop seeing these patients but no luck so far.

 

[MullerCell]

Thanks for the input. Are you routinely doing OCTs on all your cataract preops? No issues? Unfortunately, the third option here is to have the patient sign an ABN, bill the OCT and when the claim is denied let the hospital send the patient a bill. That's what they're suggesting I do and I'm not a fan. Interestingly, I have a patient who is mad at one of my partners for the exact reason you stated. He did her first eye and I did the second. Both eyes ended up 20/30 with an ERM. She thinks I walk on water and thinks he "made a mistake." He's probably the better surgeon. The only difference was the preop discussion of her retina. In my mind the $30 technical fee is a small cost to pay for happy cataract patients.

I'm a retina specialist, so I see these type of patients frequently and have to reassure them that their macular pathology had nothing to do with cataract surgery and was likely pre-existing and "just hard to see through the cataract before it was removed".

Many patients will have a billable diagnosis that you can link to the OCT (drusen, PVD, ect.) to get it reimbursed. Not that you really need it for each of those situations, but if you are doing it once pre-op, I would think is reasonable. I would for sure do it on all premium IOL patients and maybe just bundle with cost of IOL.

 

[kwr7126]

I'm a retina specialist, so I see these type of patients frequently and have to reassure them that their macular pathology had nothing to do with cataract surgery and was likely pre-existing and "just hard to see through the cataract before it was removed".

Many patients will have a billable diagnosis that you can link to the OCT (drusen, PVD, ect.) to get it reimbursed. Not that you really need it for each of those situations, but if you are doing it once pre-op, I would think is reasonable. I would for sure do it on all premium IOL patients and maybe just bundle with cost of IOL.

For some reason the list of billable diagnoses that I was given for OCT Mac by our coder is linked to things that can be treated with avastin. So wet AMD, CSME, RVO are included but not but not dry AMD, ERM, macular hole or even severe BDR without CSME. I've been thinking that this is a local insurer issue because I previously billed for OCT routinely for drusen, PVD, etc but medicare should be paying for those diagnoses regardless of location, right? As a retina specialist, how often do you do OCTs on your dry AMD patients? My main issue with these "free OCTs" is that if I don't find new SRF/IRF on the AMD patients or can't find CME under the ERM I'm stuck sending them a bill so I regret ordering it. It's raising my threshold to order them which I don't necessarily think is the best thing for patient care. Thanks again for the input!

 

[KHE]

Yeah, theoretically phni would suggest that refractive error wasn't contributing, but on a new patient you'd still check it, right? If there's no other obvious cause of decreased vision you're not going to do a whole workup without refracting just because they don't improve with pinholes. I have a subset of patients who can't figure out pinholes. They claim they can't see anything, you ask them to move the occluder around until they can see something, they claim they can't even see the big E, then they refract better. I realize it doesn't make sense from an optics standpoint. It didn't happen nearly as often with my former patient population. I have no good explanation except that I think there's some cultural component. Or it's my tech and I need to start checking VAs myself more often. Regardless, sometimes it's just easier to refract than push the pinholes. I have the same issue if they're 20/400 ph 20/50. I don't like to assume that it's limitation of the pinholes and they'd be 20/20 with refraction. I make sure they're correctable to close to 20/20 and if not I recommend we figure out why.

When I say "rough refraction" I mean I'm doing it pretty quickly with no intention of actually prescribing it. Basically I just want to make sure they're able to see, partly for my own medicolegal protection. If I put up -3.00 sph and they read 20/20-2 I don't tinker with the cyl if I'm doing it for free and they're not going to use the prescription. If they want new glasses I'll absolutely go thru the whole process to get them the sharpest vision possible. If I'm trying to document good BCVA to avoid being the guy who treated a chalazion and missed worsening ocular pathology then those 2 extra letters don't really matter. I've always thought of it as more of an extension of checking VA than as a separate service so I haven't charged. Again, it's not every patient or even every week but if doing it is actually illegal I have a bit of a problem on my hands because I don't feel good about sending people out of my office with decreased vision and no identified cause. I have definitely suggested that we either start taking the insurance or stop seeing these patients but no luck so far.

Obviously, it's ok to have someone back on a separate day when you're not dealing with the "lid lesion" or whatever but if you really need a BCVA to determine how much refractive error is contributing I would do this....

"Mrs. Johnson....I am not seeing anything here that accounts for your vision being off as much as it is. We need to test your vision. Your benefit plan unfortunately, does not cover it. The charge is $50 and I can do it now or I can you back to Dr. Optom and he can do it for whatever he charges." And you let them decide. If they decline, well....it's no different than someone declining a cataract surgery or any other medical test or intervention. It's frustrating for us as providers but it's just the way it is.

I wouldn't get hung up on whether what you're doing is illegal or not. If you want to interpret the law in the absolute most strictest sense, perhaps it is but you're not doing it to induce people to come to you or to get other services from you. There's no quid pro quo there. So in my mind, you've followed the spirit of the law.

 

[MstaKing10]

For some reason the list of billable diagnoses that I was given for OCT Mac by our coder is linked to things that can be treated with avastin. So wet AMD, CSME, RVO are included but not but not dry AMD, ERM, macular hole or even severe BDR without CSME. I've been thinking that this is a local insurer issue because I previously billed for OCT routinely for drusen, PVD, etc but medicare should be paying for those diagnoses regardless of location, right? As a retina specialist, how often do you do OCTs on your dry AMD patients? My main issue with these "free OCTs" is that if I don't find new SRF/IRF on the AMD patients or can't find CME under the ERM I'm stuck sending them a bill so I regret ordering it. It's raising my threshold to order them which I don't necessarily think is the best thing for patient care. Thanks again for the input!

I'm surprised you are having a hard time billing OCT for dry AMD, puckers, holes etc. These are certainly reasonable codes for OCT. Now if you are performing other testing then you may not get OCT paid. Or if you didn't get prior authorization etc (depending on insurance). I get OCT on these types of patients on almost every visit.

 

[hurdlepup]

Obviously, it's ok to have someone back on a separate day when you're not dealing with the "lid lesion" or whatever but if you really need a BCVA to determine how much refractive error is contributing I would do this....

"Mrs. Johnson....I am not seeing anything here that accounts for your vision being off as much as it is. We need to test your vision. Your benefit plan unfortunately, does not cover it. The charge is $50 and I can do it now or I can you back to Dr. Optom and he can do it for whatever he charges." And you let them decide. If they decline, well....it's no different than someone declining a cataract surgery or any other medical test or intervention. It's frustrating for us as providers but it's just the way it is.

I wouldn't get hung up on whether what you're doing is illegal or not. If you want to interpret the law in the absolute most strictest sense, perhaps it is but you're not doing it to induce people to come to you or to get other services from you. There's no quid pro quo there. So in my mind, you've followed the spirit of the law.

Pretty messed up to send unexplained vision loss out if vision is substantially down you need to know. If refractive error is large may not improve even with pinhole.

If exam is normal, have to be thinking other things like LHON, MAR/CAR, inherited dystrophies etc.

Shouldn't turn your brain off. Need to order ERG? Labs? MRI? How would you know if you don't have some idea of BCVA.


Sent from my iPhone using SDN mobile

 

[kwr7126]

Pretty messed up to send unexplained vision loss out if vision is substantially down you need to know. If refractive error is large may not improve even with pinhole.

If exam is normal, have to be thinking other things like LHON, MAR/CAR, inherited dystrophies etc.

Shouldn't turn your brain off. Need to order ERG? Labs? MRI? How would you know if you don't have some idea of BCVA.


Sent from my iPhone using SDN mobile

Agreed. This is exactly my issue. Just because a patient has a skin tag doesn't mean they don't also have CAR. Snipping off a lesion and sending them out, possibly never to be seen again feels unwise.

A little update on the rest of it: after a meeting with our coder and the clinic manager, it seems to be mostly a facility fee issue. Coder feels that we can't get the facility fee covered by medicare for the above listed diagnoses. The facility fee is $47 and waiving it is against hospital policy. When she says it's "against the law," she apparently means the hospital bylaws. Still a work in progress but it helps to know that you all are able to get these things covered without difficulty. Thanks everyone!

 

[KHE]

Pretty messed up to send unexplained vision loss out if vision is substantially down you need to know. If refractive error is large may not improve even with pinhole.

If exam is normal, have to be thinking other things like LHON, MAR/CAR, inherited dystrophies etc.

Shouldn't turn your brain off. Need to order ERG? Labs? MRI? How would you know if you don't have some idea of BCVA.


Sent from my iPhone using SDN mobile

Obviously, having a BCVA is the most ideal scenario. I'm not suggesting otherwise.

But in the case of a patient who doesn't want to pay for the test to determine what the BCVA actually is, does it then become incumbent upon the providing doctor to do that test for free?
At what point does the patient's own choice enter the equation?

 

[PBEA]

I think the op got his/her answers already but I just want to add that all this tiptoeing between raindrops about this test or that is a little excessive. If you think a test is a good idea then order it and charge for it. Either you are honest and your billing is valid, or you are not. Either the patient will trust you are billing honestly, or they will not.

 

[kwr7126]

I think the op got his/her answers already but I just want to add that all this tiptoeing between raindrops about this test or that is a little excessive. If you think a test is a good idea then order it and charge for it. Either you are honest and your billing is valid, or you are not. Either the patient will trust you are billing honestly, or they will not.

Respectfully, I think the issue is quite a bit more nuanced that. Coding is not always black and white. There is often more than one "valid" way to code something. It would be wonderful if being honest in your billing was enough to get appropriate testing covered every time. I'm genuinely happy for you if that's what you're finding in your practice. Unfortunately, that's not always the reality of medicine today. Frustration over insurance denials of appropriately ordered testing is pretty ubiquitous among physicians. Neurology struggles to get MRIs covered, cardiology struggles to get stress tests covered, etc. I've been ordering OCTs in situations that the majority of ophthalmologists, including retina specialists, seem to agree are appropriate and my medicare patients are getting significant bills. Some of them cannot afford those bills. I don't think there's anything dishonest about trying to figure out if it's possible to order OCTs on dry AMD patients or diabetics with decreased vision without asking them to pay cash. Yes, I could just order it, charge for it, and not worry about the financial implications for my patients. I suppose that would technically be honest. I feel that advocating for my patients is important so figuring out the details does not seem excessive even if it means "tiptoeing between the raindrops." I'd rather put in a little time to learn the intricacies of the coding than have to ask someones grandma to choose between her OCT bill and her groceries for the week.

 

[PBEA]

I agree, to say that billing/coding issues is nuanced is an understatement, and that was really my point. In some cases, it can become impossible to know with certainty what will be paid and what wont. So many variations, plans, policies, etc. All of whom have their own way of doing things. In the face of such confusion, and with good clinical reasoning, and especially with high deductible plans being so common, I don't know that it helps much to linger over whether its covered or not. With the exception of the cat pre op oct, all of the examples you give should be paid, including the refractions. I sincerely think that any of these decisions should be made based primarily on how helpful it will be (and/or necessity), with cost being a secondary concern. Sometimes a test really doesn't need to be done (and thats where the real arguments are IMO). On the other hand, if pinhole doesn't improve that new pt's vision then I agree often a refraction is indicated, should be performed, and should be paid, regardless of whether its covered. That being said I don't see why an oct should ever be an out of pocket cost (not including deductibles, copays, etc). That part sounds more like a problem with your billing dept. I'm curious, in those cases where they cant collect a facility fee, are they then billing the pt for the facility fee? If so, not sure I like that. Seems odd to me to have the actual test get paid and have the facility fee get denied, but I'm ignorant of facility billing.

 

[kwr7126]

I agree, to say that billing/coding issues is nuanced is an understatement, and that was really my point. In some cases, it can become impossible to know with certainty what will be paid and what wont. So many variations, plans, policies, etc. All of whom have their own way of doing things. In the face of such confusion, and with good clinical reasoning, and especially with high deductible plans being so common, I don't know that it helps much to linger over whether its covered or not. With the exception of the cat pre op oct, all of the examples you give should be paid, including the refractions. I sincerely think that any of these decisions should be made based primarily on how helpful it will be (and/or necessity), with cost being a secondary concern. Sometimes a test really doesn't need to be done (and thats where the real arguments are IMO). On the other hand, if pinhole doesn't improve that new pt's vision then I agree often a refraction is indicated, should be performed, and should be paid, regardless of whether its covered. That being said I don't see why an oct should ever be an out of pocket cost (not including deductibles, copays, etc). That part sounds more like a problem with your billing dept. I'm curious, in those cases where they cant collect a facility fee, are they then billing the pt for the facility fee? If so, not sure I like that. Seems odd to me to have the actual test get paid and have the facility fee get denied, but I'm ignorant of facility billing.

Of course I'm making the decision of whether to recommend testing based on medical necessity. That doesn't make trying to minimize the cost to the patient useless. I have a lot of medicare patients and many of them have AMD so that one is a large number of patients, not an occasional problem like the refractions. Just because testing "should" be covered doesn't mean that it is. That's where my problem lies. They are currently billing a $47 facility fee for medicare patients without CME or SRF on OCT. I've gotten the "right" to waive my professional fee but apparently waiving the facility fee is against hospital bylaws so thus far I'm unable to avoid it. I'm waiving my professional fee largely because I still suspect the charges are either the result of poor contract negotiation on our end or a mistake with billing and I don't feel its fair to pass that cost, which is above the local market value, on to the patient. Meeting with higher-ups to discuss today. We'll see.