What to Do When You're Denied Compensation

Optometric Management, Jul 2004 by Weber, Gil

Some payers deny compensation for proper patient care and also declare that you can't bill the patient.

Some third-party payers tell practices that CPT 92135, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI), is a noncovered service and is therefore not reimbursable. Some even declare that practices can't bill patients. If you've experienced such a compensation denial - or if you code for CPT 92135 - then read on. I'll tell you how to improve your chances for reimbursement when insurers don't pay.

That was then

Years ago, if an insurance plan didn't cover a service or a procedure, then a practice could simply tell the patient that his insurance didn't cover the service or procedure and that he was financially responsible for the charges. The patient would agree to pay and that was that.

In recent years, managed care plans have asked practices to get the patient to sign a financial responsibility acknowledgement form before providing noncovered services. And until recently, that simple protocol adjustment was sufficient in most instances.

Practices almost always knew what services or procedures the insurance plans wouldn't cover, and these noncovered items were what you'd reasonably expect. For example, elective/cosmetic services and procedures were a patient's responsibility, as were "upgrades" such as designer eyeglass frames. The noncovered services were similar from plan to plan so you almost always knew up front what was what.

This is now

But now some payers routinely deny coverage for certain services and procedures that reasonably seem to warrant coverage. It's frustrating when the eyecare profession adopts new technologies as the standards of patient care, but payers ignore them.

CPT 92135 has become particularly troublesome for practices across the country, in large part because Aetna, a major insurance player, has promulgated a national policy that classifies SCODI as "experimental" and therefore not reimbursable.

But to make matters worse, on top of denying financial responsibility for the care, some plans (including Aetna) have gotten between the practice and the patient by putting up impediments to charging the patient for these noncovered services.

Drawing comparisons

So how can you avoid situations where a payer's rules would cause you to work for free? Finding the answer to this problem is complicated because today, what an insurance plan covers isn't always clear.

We know what Medicare covers. For example, when we use the OCT (Zeiss), GDx (Laser Diagnostic Technologies), HRT (Heidelberg) or RTA (Talia), Medicare will pay us for care that we bill under code 92135. Medicare also reimburses many practices when they use these instruments for nonglaucoma-related cases (e.g., confirming a diagnosis of cystoid macular edema). Note: these devices have multiple but not necessarily identical uses.

But with some commercial health plans, the coverage and reimbursement situations are anything but clear and tend to vary. Some plans refuse to pay 92135 in all cases, deeming it experimental or investigational, or they deny the code as "screening" for glaucoma.

In Aetna's case, it seems to base denials on an outdated Preferred Practice Pattern (PPP) from the American Academy of Ophthalmology (AAO). And though the AAO updated the Primary Open Angle Glaucoma PPP last year to include results of recent studies showing the benefits of these new technologies, claims processing personnel at Aetna continue to refer practices to a policy published on Aetna's Web site (www.aetna.com/cpb/data/CPBA0344.html).

Of course, these denials run contrary to Medicare's protocols, which will surely pose a significant problem for doctors, staff and patients. Some payers do recognize the new technologies and reimburse for 92135. Others state that 92135 is a noncovered service and is therefore not subject to payment by the plan, but they also make it clear that practices may bill the patient for the service if they first meet certain conditions. (The practice must inform the patient that insurance won't cover the service, and the practice must also obtain and place in the chart a signed patient agreement to pay for the service before the practice supplies it.)

Still, other plans tell practices that 92135 isn't covered, yet upon appeal they'll (inconsistently) pay the claim. That consistent inconsistency leaves the practice in limbo during the patient visit and throughout the claims processing and appeals period. But things can get particularly frustrating and irritating when a plan allows the practice to bill a patient for noncovered services but then tells the patient that 92135 is covered (i.e., provided at no charge) while simultaneously telling the practice that it's not.

Pursuing payment

Any time a payer rejects a claim as noncovered and that rejection seems based on flawed logic or misinformation, you'll immediately need to appeal the rejection. That's the first part of a bifurcated approach to getting paid. (I've also included a sample letter, on page 52, that you can use as a model for appeals to any insurance company).