Managed Care

How Obtaining Prior Authorization for Specialty Fits Improves My Patients’ Experience

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By Stephanie Woo, OD, FAAO, FSLS

The management of patients needing specialty contact lenses presents many challenges, not the least of which is ensuring that the patient and practice are getting maximum reimbursement from their insurance regarding covered services.

To ensure that your practice is receiving the highest reimbursement and minimizing surprises for the patient on the day of the exam, obtaining prior authorization from a vision or medical benefits plan is key.

We have learned this lesson the hard way. Originally, we used to get this authorization while the patient was in the office, but it was inefficient and occasionally extremely disappointing to the patient who was now in the office facing a difficult financial decision. By handling this process in advance of the patient’s visit, we’ve been able to resolve about 95 percent of our billing issues. Obtaining the authorization beforehand has improved our experience and the patient’s – and has impacted our bottom line positively.

Educational Opportunity

Dr. Woo is a presenter for ABB OPTICAL GROUP’s practice development webinar series, Building and Growing Your Specialty Contact Lens Practice.

She will host the fourth webinar in the series, “Practice Management Tips for Billing and Coding and other Issues to build your Specialty Contact Lens Practice” taking place on Thursday, Dec. 12, 2019.

To watch past webinars and register for the next session on Tuesday, Sept. 17, visit ABBOptical.com/webinar-series.

Schedule a Consultation Visit
Whenever possible, I see a specialty lens patient first to determine what kind of disease may be present and what contact lenses are indicated. That visit provides me the opportunity to develop a plan that includes the type of specialty lenses that will be most appropriate. We schedule the fitting, leaving enough time to ensure that we can obtain the prior authorization. Remember that these calls may require a follow-up or even the doctor’s participation in part of the call, so reschedule the patient for at least several days out to allow the process to unfold.

Be Prepared
Before contacting the benefits plan carrier, have the following three pieces of information on hand: patient’s diagnosis or diagnoses if more than one, the CPT fitting code you’re using and the V-codes for the contact lenses you expect to be prescribing. The carrier’s representative will confirm whether this is a covered benefit.

If it is covered, determine precisely what that means in terms of reimbursement. Is this an acceptable rate for this type of lens? If it’s not, is there someone the staff member can talk with who might be able to adjust the reimbursement rate?

If it is not a covered benefit, it will be critical to call the patient and explain what his or her out-of-pocket fees will be for the entire visit, including services and lenses.

Document Your Calls
Our office tracks the name of the representative we spoke with during the authorization request. It’s important to document all conversations with a carrier because some of these questions may require a follow-up call. Be sure to ask for a reference or encounter number to enable the next representative to look back at the notes, too.

Note also when the patient was contacted and what the patient was told about his or her coverage benefits and out-of-pocket expenses.

The time spent obtaining prior authorization is valuable. The patient’s experience is enhanced when they know what to expect. If the patient’s out-of-pocket costs are out of reach, the patient will be able to make that decision without the pressure and discomfort of learning about that in the office. This process also allows the practice and the patient to look at alternatives, such as using a patient financing credit card or asking for an appeal from the third-party provider.

Not only does prior authorization minimize surprises for the patient, it also eliminates surprises for our billing department, as we have been able to maximize our reimbursement and the turnaround time for getting paid.

 

Dr. Woo is in private practice in Lake Havasu City, Arizona. She is also a presenter for ABB OPTICAL GROUP’s practice development webinar series, Building and Growing Your Specialty Contact Lens Practice. Dr. Woo will host the fourth webinar in the series, “Practice Management Tips for Billing and Coding and other Issues to build your Specialty Contact Lens Practice” taking place on Thursday, December 12, 2019. To watch past webinars and register for the next session on Tuesday, September 17, visit ABBOptical.com/webinar-series. You can learn more about Dr. Woo by visiting her web site: www.clinevada.com

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