Medicare post-cataract eyewear sales: Are you losing out?

I have been analyzing post-cataract eyewear sales and claim filing for physician dispensaries for years. As physician dispensing increases, it is unfortunate to see that neither the practice's patients nor the practice's dispensary have reaped as many benefits as they could had these transactions been handled better. Most of the filings I review are either incomplete or incorrect in the 1500 form paperwork, miscalculated or misquoted in pricing (usually at a loss to the dispensary), or a combination of both!

Let's review the key issues. Cataract surgery reimbursements have been on the steady decline in past years. Yet, a practice that does substantial surgeries and an increasing, aging baby-boom generation that needs this surgery can mean an excellent source of revenues for the physician dispensary.

The doctor issue aside, the greater issue appears to be in the dispensary. First, it is important for the practice dispensary not only to be a supplier, but to accept assignment for post-cataract eyewear.There are many good reasons for this, including patient satisfaction and increased dispensary revenues, because the eyewear job averages can be greater if you accept assignment.

Train your dispensers Next, your dispensers must be trained on how to work with Medicare post-cataract eyewear. They must understand the V code fees and structure, make sure that the patient pays for non-covered items, and make sure the Advanced Beneficiary Notice (ABN) is accurate. Your billing department must be given the correct information to fill in the 1500 forms, and this information is generated by the optical department.

Some of the common mistakes I have seen include: the optical department does not properly calculate what Medicare (and secondary insurer) will pay, the patients are not charged the correct amount for the non-covered items they opted to purchase, and all the appropriate V codes for that pair of eyeglasses are not listed on the claim. If you do not inform the patients accurately of the items they are responsible to pay for and the patients sign the ABN, you cannot collect for these items later. I have seen hundreds, even thousands, of dollars being lost by practices that are not diligent about these issues.

Here are a few more key tips to make sure your claims are filed properly.

1. If the patient has a secondary insurer, with Medicare as their primary insurer, be sure to put the Other Carrier Name and Address (OCNA) on line 9d of the 1500 form. Put the number, then the letters "OCNA". You can find the OCNA numbers of these insurance companies listed on your DMERC Region's Web site. If a patient has an insurer that does not appear on this list, call the insurance company directly. Be aware that if you do not fill in the secondary insurer, Medicare does not guarantee that the claim will be forwarded. Consequently, you will not receive the 20% from the secondary insurer, after Medicare pays the 80%. I have seen practices write off the 20%. This is entirely unnecessary. You can collect it, if you do the paperwork right!