PRE-APPOINTING FOR SUCCESS Learning Objectives: 1) Learn the difference between a recall system and pre-appointing system and why one works better than the other. 2) Learn how to deal with no shows and cancellations. 3) Learn the timeline and associated benchmarks. Technical General Knowledge x Level: Basic_x Intermediate Advanced I Introduction: 2 minutes A consistent patient flow and a full schedule book help to ensure the profitability of the office. There is more to pre-appointing than just telling the patient to return on a certain date a year from now. We are going to look at the steps involved in ensuring that the patients return when they are supposed to. These steps are initiated by you and are not reliant upon any action by the patient who will most likely forget to make an appointment or forget when their appointment is. Remember, no patient appointment, no patient; no patient, no office revenue; no office revenue, no salary; no salary, no you! II Initial Visit A. Doctor 1) Tell the patient during the exam when you want them to return. 2) Explain why you are having them return (Test, follow-up, yearly exam, etc.). 3) Stress the importance of keeping appointments 4) Do this when the staff member you will be passing them to is present if possible. B. Staff 1) Make the next two appointments the doctor has scheduled for the patient. For example: VF, photos, and then their yearly exam. 2) Have the patient complete the confirmation card for their yearly exam. 3) If the other appointment is within one month, you do not need a confirmation card. But, if it is over one month, you complete the confirmation card for that visit. 4) Give the patient an appointment card for each appointment you have made for them. 5) Put the confirmation card in a box under the month they will be returning. IF A PATIENT DOES NOT LEAVE YOUR OFFICE WITH AN APPOINTMENT CARD, THEY DO NOT HAVE AN APPOINTMENT!!
II Set Recall for Patient: 5 minutes Set a recall on the computer for each patient as a back-up if they do not keep their scheduled appointment. They will be on your recall list to get a card reminding them it is past time for their appointment. III One Month Before Appointment Mail Out the Confirmation Cards A. Every two weeks pull out the confirmation cards for the corresponding weeks of the next month and mail them out. B. The patient needs to receive their confirmation card one full month before their appointment. C. The confirmation card should have the patient s appointment time, date, and a statement that they need to call our office to confirm their appointment within the next 48 hours. IV Two Weeks Before Appointment A. Pull up your schedule on the computer and call all patients that have not called you to confirm. B. Try first thing in the morning and any you cannot reach, call them back in the late afternoon. C. Make at least three attempts to confirm wit the patient at different times during the day. D. If a patient cannot be reached after three attempts, double book the appointment E. This is best done at the beginning of the week so you have two weeks to refill that appointment time. IF A PATIENT IS NOT CONFIRMED ON THE SCHEDULE TWO WEEKS PRIOR TO THEIR APPOINTMENT, ASSUME THEY ARE NOT COMING!! V Day Before the Appointment: Reminder Call A. Call all confirmed patients to remind them of their appointment the following day. B. If you have unconfirmed patients that you have not double booked, try to reach them and confirm the appointment at that time. C. The unconfirmed appointments that have been double booked, try to reach them to reschedule for a time that is good for them. VI One Month After Appointment: Recalls for Cancellations and No-Shows A. Any unconfirmed patients who do not show for their appointments or any patients that cancel their appointments and do not reschedule for another time should appear on your recall list. B. Pull your recalls for the previous month and send a recall postcard stating it is past time for their eye exam or print a call list call those people to reschedule them.\
DO NOT LET THESE PEOPLE FALL THROUGH THE CRACKS BECAUSE THEY ARE ON A TREATMENT PLAN! THEY ARE OUR RESPONSIBILITY AND WE ARE LIABLE FOR THEIR EYE HEALTH!!! SUMMARY: 2 minutes As you can see, you are the driver. The only response required of the patient is to call and confirm within 48 hours. If they do not, you take the initiative and begin calling them. If you are unable to contact them, you fill their spot with someone else so when that appointment time comes you are not sitting their hoping someone will show up. Remember, no appointment, not patient; no patient, no revenue; no revenue, no job!! Learning Objectives: INSURANCE FILING 1) Learn that each area of the office has a responsibility in creating a clean claim that will be paid by the insurance company. 2) Each area of the office will learn what their responsibility is to ensure that a complete and clean claim is submitted to the insurance staff person for filing. 3) Learn the claim requirements for DMERC and the use of modifiers. Technical General Knowledge x Level: Basic Intermediate x Advanced I II Introduction Insurance is a large part of the revenue in a practice today. It is essential to establish a system for collecting information from the patient, creating a clean claim, and ensuring payment is made correctly and in a timely manner. You will soon see that the responsibility for accomplishing the three steps listed above is shared amongst the entire staff, not just the insurance staff person. Check-In A. Collecting pertinent information to file insurance begins when the patient calls for an appointment. B. When making an appointment, always ask the patient What is the reason for the appointment? C. Ask for their medical insurance and their vision insurance.
D. You will need the following information so you can get an authorization for the patient s insurance coverage: 1) Patient s full name 2) Patient s SSN 3) Patient s DOB 4) Patient s Home Phone 5) Insured s (if not the patient) full name 6) Insured s SSN 7) Insured s DOB E. Authorization should be done at least the day before the patient s appointment so if they are not eligible, you can call them and let them know insurance will not cover at this time and give them the option to pay for the visit or reschedule when eligible. Then you have time to fill and open appointment time before the next day. F. If the patient has VSP or other vision coverage, be sure the authorization print out is in the chart so the optician knows what is covered on glasses since each plan is different. G. When the patient arrives for their appointment, you need to make a copy of their insurance card, front and back. H. Always replace the copy of the card in the chart unless it has been three months or less since the last visit then ask for the card to double check that the name on the card matches the patient s name and the number is the same. I. Medicare numbers change at times. The following are the numbers they use and what they represent: 1) SSN with an A- the patient s coverage is through their own social security 2) SSN with a B- coverage is through their spouse s social security and the spouse is living. 3) SSN with a D- coverage is through their spouse s social security and the spouse is deceased. 4) SSN with a C and a number- This is a grown child drawing on a parent s social security. An example is a handicapped adult or child that has never had an income and they are drawing on a parent s social security. J. If you see a Medicare number with the letter before the numbers, that will be Railroad Medicare and should be filed to a different carrier. K. DMERC (Durable Medical Equipment Regional Carrier) which is the carrier who handles Medicare s materials claims is also sent to a different carrier but their number will come off of their Medicare card. There is no separate card for this. This includes any claims for glasses and contact lenses. L. Most of the insurance companies are in the process of changing the patient s identification to remove their SSN from their insurance cards in order to be in compliance with HIPPA.
M. With VSP and some other vision care providers, the patient will not have an insurance card. N. The name on the card must match the name in the computer exactly. If you are filing electronically, this is imperative because when the carrier gets the claim it will either be delayed in payment or denied. III IV V Pre-Test A. You are responsible for making sure the Medical History form is completed before the patient gets to the doctor. B. Part of the history taking is getting a valid chief complaint (CC) and four history of present illness (HPI). C. Make sure all writing is legible. D. If you use any abbreviations you must have a list of those with what each represents. E. Initial after the last entry you make on the patient s exam sheet. Doctor A. The doctor s handwriting must be readable (Auditors must be able to read the handwriting themselves, not translated by doctor or staff). B. Make sure you have sufficient history and have checked enough elements of the eye in your examination with the proper documentation to warrant the procedure code you are billing. C. The date of service on the claim must match the date on the exam sheet for that visit. D. The doctor s signature must be on EVERY exam sheet and EVERY medical history. E. If the Medical History is being reviewed by the doctor rather than a new history, that must be noted on the exam sheet with a place for the date of the history being reviewed and the doctor s initials. Optical A. When the insurance patient comes to the optical, be sure they are treated the same as a private paying patient. B. Always look at anything that is checked on their information sheet and also what the doctor has checked that he has recommended. Never assume they only want what their insurance will cover because it is your job to let them know what is best for them. Then let them know what their savings is over your normal prices. C. For Medicare patients getting glasses after cataract surgery, you have to have an Advanced Beneficiary Notice (Form CMS-R-131-G). D. The Advanced Beneficiary Notice should state each item that they are getting that will not be allowed by DMERC and why they will not be covered. The total of these items should be listed along with a beneficiary agreement below with the patient s signature. E. Make sure all vision claims are filed daily, especially VSP because the glasses are ordered at the time of the claim.
VI VII VIII Check-Out A. Make sure all charges are entered correctly and the claim is created properly. If this is not done correctly, the insurance person will have to make too many changes when they are proofing the claim. It should be just that, PROOFING, not re-doing the claim. B. Collect all co-pays, deductibles, and any other non-covered items at the time of check-out. C. Most vision plans require to collect co-pays and non-covered items before you file the claim with them. Insurance Staff Person A. Insurance claims can be filed daily or weekly according to the number of claims you file, but they should never be held over a week to ensure prompt payment. B. If you send claims weekly, you should choose a day of the week and always proof and send on that day of every week. C. Each claim should be proofed before it is sent to the appropriate insurance carrier. D. Any claims that are denied on an EOB from an insurance company should be corrected and refilled that day whenever possible but no later than the following day. E. The insurance person should return each incorrect claim back to the person responsible for the incorrect entry so they will be aware of the mistake and the correct way it is to be filed. That is the only way they will learn the correct way to file each claim. F. You need to run a monthly insurance aging report that shows all insurance 30 days or older and each unpaid claim needs to be checked for incorrect billing and corrected if needed. If claim is correct call the insurance company and inquire as to why it has not been paid. Any carrier you are electronically billing should not have unpaid claims over 30 days. G. If you are not being paid in a timely manner from any insurance company, they should be contacted and asked for an explanation for the delay in payment. Insurance Claim Requirements A. Each insurance company has certain requirements that have to be met when filing their claims. B. They have realized that they can audit offices and usually find a sufficient percentage of claims that are incorrect and recoup money from the provider. C. All claims should have sufficient history, eye exam components, and proper documentation to support the codes billed. D. Most medical and vision plans have these requirements posted on their websites or it is available in their printed manual.
IX DMERC (Durable Medical Equipment Regional Carrier) Claim Requirements A. The date on the DMERC claim for glasses has to be the date the glasses were dispensed. If the date is before the patient picks up the glasses the claim will be denied if questioned or in an audit. B. Non-covered items do not have to be listed on the CMS claim form but if the patient requests they be filed to Medicare list each item with a GY modifier attached to the material code. Non-covered items: 1. V2760 Scratch resistant coating 2. V2761 Mirror coating 3. V2762 Polarization 4. V2702 Deluxe lens feature 5. V2781 Progressive lenses 6. V2745 Tint (Used as sunglasses) 7. V2744 Photochromic lenses (Used as sunglasses) 8. V2782, V2783, Polycarbonate or similar material, V2784 High Index Glass or Plastic for indications such as lightweight or thinness. 9. V2786 Specialty occupational Multifocal lenses 10. V2025 Deluxe frame (Anything over the amount allowed by Medicare for a frame). C. Items that could be covered if deemed medically necessary by Medicare must be documented and written on the order for glasses by the treating physician. If they are not medically necessary for this patient they do not have to be listed on the CMS form unless the patient wants it filed. If it is put on the claim form, list the material code followed by an EY modifier to indicate not ordered by the doctor but a patient preference item and a GA modifier to indicate ABN on file. If you do not list the GA modifier, the Explanation of Benefits that goes to the patient may say not covered by Medicare and you are not responsible. Items Covered With Medical Necessity Only: 1. V2750 Anti-reflective coating 2. V2744, V2745 Tints and Photochromic lenses 3. V2780 Oversized lenses 4. V2784 Polycarbonate or Trivex material (patients with functional vision in only one eye) C. V2755 UV Protection is considered reasonable and necessary following cataract extraction and does not require medical necessity justification. The only time it is not covered is on lenses with UV protective properties inherent in the material such as polycarbonate or Trivex. D. When the patient gets a progressive lens that is not covered by DMERC or a frame that costs more than is allowed by DMERC each has to be listed on the
ABN and also broken down on the CMS claim form to DMERC with the RT and LT modifier and the GA modifier. Examples of how these charges would be billed are as follows: Progressive Lens V2303RTLT Units 2 Trifocal Lens V2781RTLTGA Units 2 Extra for Progressive Lens Frame V2020 V2025GA Frame Deluxe Frame (Overage of what Medicare allows) E. Medicare allows one pair of glasses after each cataract surgery with a IOL implant. If the patient does not receive a pair of eyeglasses between the two surgical procedures, they are only eligible for one pair of eyeglasses after the second surgery. F. If a patient receives only lenses after the surgeries and not a new frame, a new frame would not be covered at a later date. Summary As you can see, insurance filing involves a lot of people doing their part to make sure all information is gathered, filed properly, and is submitted and paid in a timely manner. I hope you will work as a team to make sure it is not left up to one person, but each person doing their part to make sure insurance filing goes smoothly.