On Becoming a 3rd Party Provider

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

2DisclaimersThis 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.

3Disclaimer 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.

4Types of 3rd Party PayersRoutine Vision Care (prepaid care)Medical (health insurance coverage)

45Types of 3rd Party PayersRoutine (pre-paid) CareCover Exam and materialsLimits on frequency Limits on materialsDoes not pay for medical services (fields, gonioscopy, retinal photos)Generally file over Internet or may use own claim forms

56Types of 3rd Party PayersRoutine examples:VSPEyeMed (Eye Care Plan of America)Optum Health (Spectera)Medicaid (patients w/o medical diagnosis)

67Types of 3rd Party PayersMedical (health insurance coverage of eye Dx)Medical diagnosis only (not refractive codes)Pays for other medical services (fields, photos)Rarely pays for materialsFile electronically using HIPAA approved format (5010 electronic claim format soon required), or File on paper CMS-1500 formsOnly okay if less than 10 FTE employees 5010 format coming up

78Types of 3rd Party PayersMedical examples Blue Cross Blue ShieldCoventryUnited Health CareMedicareMedicaid medical coverage

89Should You Become a Provider?Dont have to be provider; rather canGive Patient super-bill or a printed claim formPatient pays your fee to youPatient sends claim to InsurerInsurer pays patient their allowableException: MedicareIf you see a Medicare patient, you must file the claim for the patient.

910Should You Become a Provider?Thus, the advantages of not being provider:Full fee(Medicare has fee limitations on non-participating providers)Dont file claims (Must file Medicare)No limit on services provided (except Medicare)

1011None Provider:Accepting AssignmentIf 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 do not Accept Assignment, the insurance payment goes to the patient, and the patient (hopefully) pays you.

1112Should You Become a Provider?Advantages of being a providerOn provider list (strong patient resource)Fewer $ collection problemsPatient happy Doesnt have to file own claimLess $ out-of pocket Fees seem more reasonable than out-of-plan providers fees

1213Should 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 can only bill the patient for deductible and co-pay. You cannot balance bill for the rest of your fee.

1314Should You Become a MEDICARE Provider?If you see ANY Medicare patients, you must follow ALL Medicare rules.You have a choice of Participating or not Participating Medicare Provider.

1415Participating Providers are paid directly by Medicare using their Par fee scheduleNone-Participating Providers Medicare will pay the patientThe patient will (hopefully) pay you.What you charge a Medicare patient is limited by Medicares limiting charge. You cannot bill beyond the limiting charge. http://www.wpsmedicare.com/j5macpartb/fees/general_fee_info/b_limiting.shtmlShould You Become a MEDICARE Provider?

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Should You Become a MEDICARE Provider?

17Medicare Advantage (MA)Privatization of Medicare Medicare charges patient then pays insurance companies a capitation amount per patient Claims are filed with these MA companies, not with traditional MedicareMany patients do not understand they are no longer covered directly by MedicareShould You Become a MEDICARE ADVANTAGE Provider?

1718Medicare AdvantageCost to patient may be the same as for traditional Medicare, or there may be an additional charge over traditional MedicareMA policies may have different co-pay amounts and deductibles than traditional MedicareSome plans offer additional benefits (dental care, routine vision, drug coverage included)Should You Become a MEDICARE ADVANTAGE Provider?

1819Medicare Advantage comes in a variety of typesHMO: Patients see only HMO panel doctors; panel networks small; providers accept HMOs feesPPO: Panels more open; some out of panel coverage; providers agree to accept PPO feesPFFS (Private Fee For Service)next slideShould You Become a MEDICARE ADVANTAGE Provider?

1920PFFS (Private Fee For Service): No networks, More expensive to patients, Pays provider per its fee schedule, Provider does not sign up to be in networkIf you accept a PFFS MA patient, you are deemed to accept their fee schedule.If in doubt, check on reimbursement before seeing patient.Should You Become a MEDICARE ADVANTAGE Provider?

2021A list of the Medicare Advantage plans found in Nebraska can be found at a Medicare web site, http://www.q1medicare.com/MedicareAdvantage-PartCHealthPlanMAPDHMONebraskaNE.php

Should You Become a MEDICARE ADVANTAGE Provider?

2122Thank You for ListeningWe hope this information has been helpful.Thank you for listening!See our NOA Website for more 3rd Party Educational Videos.

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