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This is the e-mail I just sent to BlueCross:

Dear BlueCross,

It is with regret that I inform you that I wish to terminate my contract with BlueCross and no longer be in your network. I understand that I have to continue seeing BlueCross patients for 90 more days.

If you are interested in why I am leaving you, my accounts receivable with BlueCross patients is unacceptably high.

Since I am an optometrist, I need fast, easy access to whether a member has a routine eye exam benefit (S0620, S0621) and whether a contact lens evaluation is covered (92310).

For non-Regence plans, I have to make lengthy phone calls and navigate through terrible phone trees before finally talking with a representative. This process takes longer than performing the actual exam.

While Regence has a nice website for explaining benefits and is good about paying what I expect, every other BlueCross association is unpredictable about paying what I’m expecting. I often have to send out statements or refunds. Usually statements. Hence the high accounts receivable.

I know this will hit you in the wallet as well since I am the lowest-fee eye doctor in Cache Valley. If in the future BlueCross comes out with a website that allows an optometrist to see vision benefit details for any BlueCross member from any state/association, then feel free to let me know, and I’ll reconsider. I would also reconsider if a new rule allowed one to participate only with Regence and exclude all other BlueCross associations.

Sincerely,
David J. Langford, O.D.

I find it unacceptable in this day and age that I can’t look up vision benefits for an entire insurance company in one place. This probably has something to do with BCBS being independent associations instead of one giant insurance company. It is still ridiculous and a big pain in my side that won’t be there in 90 days.

I feel sorry for my BCBS patients. If it’s any consolation, the Utah State University BlueCross beneficiaries can send in their receipt and get 70% reimbursed for a routine eye exam done out-of-network. Not bad.

Utah Medicaid is changing their copays for 2014:

For Non-Traditional (Blue Card), they used to only cover the first $30, then you would pay the balance. Now, at my office your routine eye exam is covered without any copay since I am an optometrist. (At an ophthalmologist office, there is a $3 copay.)

For Primary Care Network, a.k.a PCN (Yellow Card), you used to have a $5 copay. For 2014, there is no copay on the routine eye exam at my office since I am an optometrist. (At an ophthalmologist office, there is a $3 copay.)

For Traditional (Purple Card), there is still no copay for 2014 on a routine eye exam.

I think it’s funny how the patient pays less to see an optometrist vs an ophthalmologist. On the face it doesn’t feel fair. Theoretically, for the same procedure code, why should the patient pay any different?

Practically, OMDs charge more than ODs, so maybe this is a way for Utah Medicaid to incentivize “clients” to see an optometrist instead of an ophthalmologist. OMDs could be miffed, but they probably aren’t because $3 isn’t that big of a penalty; therefore, it should cause very few patients to actually alter provider choice.

Still, it’s curious. I wonder at what OD/OMD copay differential the OMDs would become vocal.

Well, this was annoying. I did a favor for a patient and billed an insurance that I’m not contracted with but which allowed any provider to bill them.
Instead of the mailed EOB including a check, it had a graphic of a credit card with its number, expiration, security code, and zip code.
They call it “QuickRemit, virtual prompt payment.” (I guess by prompt, they mean 6 weeks from date of service.)
If I didn’t have a merchant account, I wouldn’t be able to process the funds. Luckily I have Square that allows me to punch in the numbers to get paid from a card not present, but I find it really annoying that I lost about 4% of the payment because the insurance company chose not to sent a check!
I wonder what the benefit is for them to do this. I get charged to process the payment and I’m sure they get charged to charge a virtual credit card. So, why not send a check, Insurance?

Guy with thick accent (Indian?) holding up $9.99 sunglasses: Do you have anything cheaper than this?
Optician: Over in jewelry there are more sunglasses.
Guy: Yes. Cheaper?
Optician: I don’t know for sure, but probably a few might be cheaper.
Guy just stands there.
Optician pointing to jewelry: Over in jewelry.
Guy: Where?
Optician: Look right over there. Jewelry.
Guy: Sunglasses?
Optician: Yes, a different selection over in jewelry.
Guy: Cheaper?
Optician: You’ll have to look and see.

I did an eye exam almost 3 years ago. The patient paid their copay. A couple weeks later the insurance paid the rest, a whopping $15. Almost three years later the insurance said their payment was made in error, so I have to remit to them a check for $15 or else a future EOB would have $15 deducted.
Whatever, they can deduct it, but I ain’t sending a check. Do they expect me to send the patient a statement for $15 for an exam from three years ago? Never mind the patient has probably moved, and even if they haven’t, they will probably shrug off the statement like I did from the insurance.
A month later the insurance takes $15 from one of my EOB payments. Luckily I don’t bother billing the patient because a week later, they sent me a check for the same patient’s three-year-old visit!
Make up your mind, insurance company!
[UPDATED: Today BCBS sent me ANOTHER letter saying that they overpaid me for this patient when they repaid me! Eat poop, BlueCross!]

I had a patient who has a really big head and his regular size glasses were making an indented, red scar in front of his ears. Of course I recommend the largest style frame we have called FatHeadz. He finds one he likes, and it fits his head perfectly. The optician enters the order, but the lab calls and says they can’t make it. It turns out he has a small PD; therefore, they don’t make a lens blank large enough for his combo of large frame, small pd. Poor guy.

A urologist posted a sign at his office, and some people are going nuts.

Obama voters not wanted as clients.

So…I’m not sure I would pick that fight because I just want money in exchange for services, but if I felt that a certain person or entity were actively fighting against me obtaining patient volume and deserved fees, then yes, I would have to push back.

This doctor also put some literature in his waiting room about the negative effects of Obamacare and its timetable. Holy cow, imagine the left’s vitriol if you stuck a Bible in your waiting room! I put NRA magazines in my waiting area, and guys love them! I also put National Geographic in there too. You know, just to keep it balanced. I think it’s the doctor’s right to put any decent reading material he wants in the waiting room. No one is forcing them to read it. They can take their business somewhere else if they want.

I’ll bet 80% of my patients don’t even know what magazines I have in my waiting area since I don’t like to keep people waiting.

I’m still participating in Medicaid until it doesn’t make it worth my while. I don’t really agree that there is such a thing as government sponsored-medicaid, but for now I think of it as getting my own tax dollars back.

Anyway, I reserve the right to express my political, economic, and religious views to anyone who will listen, inside or outside the clinic. Just because I’m a doctor doesn’t mean I can’t be active in causes I believe in. However, I don’t think people pay me to preach to them. I’m pretty sure they came in for an eye exam. Plus I don’t have time to go off on political or religious rabbit trails because I hope the next patient is almost done with their paper work.

I don’t care what a patient’s political/religious/etc philosophy is. I don’t care if I have to speak to them in English or Spanish or through a family member interpreting, I just want a fee in exchange for a service, and I want to perform as many exams per day as possible.

Is there anything I can do to not get that gunk buildup by the nose pads?
An ultrasonic cleaner will take out the gunk. To help it not build up, try cleaning your glasses daily under the sink with dish soap that doesn’t contain lemon.

Yesterday I didn’t have to bill a single insurance. I love no insurance days.

New phones chirp like the phones in IHS used to. They also chirp louder and more frequently if no one picks them up quickly.

Lately people are confusing the non-contact tonometer with dilation. “Okay, I’m going to put some drops in your eyes to dilate them.”
“Didn’t we already do that with the puff of air?”
“No, that was just an eye pressure measurement.” (I already explained that when doing it, BTW.)

AlwaysCare website is down, probably due to hurricane Isaac since the call center is apparently in Baton Rouge. Earlier in the day, the website just timed out. Later it has this message: “AlwaysAssist website is currently having technical difficulties.. Please check back later to access any information. Thank you for your patience. For immediate assistance, please call [toll-free and local numbers] in Baton Rouge. ”

Of course all circuits are busy when you try to call that number. I think it’s ridiculous that they don’t have redundant servers across the country available. I guess these hurricanes inconvenience everybody…

This week I heard about a New York physician telling all his medicaid patients that they had HIV/AIDS, even though they didn’t, because he could bilk Medicaid for tons of money running HIV testing/office visits.

Today I hear about an optometrist in Utah who bilked Medicaid for patients he never even saw!

Before insurance companies (especially government ones) start bearing down on all of us with burdensome regulations because of a few bad actors, let’s take a step back an look at the problem from a different angle.

This is why insurances shouldn’t pay for physician office visits, but if they want to, then leave the doctor out of it and just reimburse the patient. My car insurance doesn’t pay for oil changes or gasoline. If my car insurance was crazy enough to offer an oil change benefit, then that would be great, but if I’m Convenience Lube, then no way would I take deferred payment from some car insurance company. I would demand the car owner pay at the time of service, and their crazy insurance company can reimburse the car owner later. If my car is in a major accident, then I would less likely have cash on hand for an expensive repair, so this is when the insurance companies would step in. Besides, autobody shops are much more accustomed to dealing with insurance compared to oil change shops or gas stations.

This is how it should be in healthcare. Only certain providers would really have a need to regularly bill insurances. Mostly doctors doing surgeries, hospitals, or other high cost care environments.

Number one, this helps lower the cost of medical care because people find out how much it actually costs since doctors don’t have a big menu/price sign over the reception desk. Second, doctors don’t have to spend tons of money and time filing claims. Third, the incidence of doctors perpetrating insurance fraud would go down because doctors would have less opportunity anyway. Fourth, if something isn’t covered by insurance, who presently gets to eat it? Usually the doctor. Patients paying their own office visits would force the patient to be more accountable for whether they really want/need a particular service, regardless if they expect their insurance to reimburse or not.

The doctor shouldn’t be beholden to any insurance company. He should deliver care according to his training/experience. She shouldn’t have to try to remember that Insurance A will pay for a visual field once a year, but Insurance B will allow it twice a year, etc. He shouldn’t think about if he has the patient do an extended medical history, he can upgrade his exam from level 3 to level 4 to bilk the insurance company for all they’re worth because hey, the patient is only paying a copay, right?

I think big ticket items like billing for surgeries or expensive procedures should still be billed by providers/hospitals since this is what insurance is for: paying for catastrophic, unexpected events. But all the little stuff, like inpatient food service and routine exams and regular office visits should be paid up front by patients. It would lower healthcare costs because providers could lower prices since their labor and accounts receivable would decrease. It would decrease over-utilization since patients have a financial stake in the process. It would decrease fraud since there would be less opportunity to create fraud by the majority of doctors/patient encounters.

I tried billing corneal topography (92025) to Utah Medicaid as part of managing a patient’s keratoconus, and I was shocked to have it denied. The reason?

The procedure code is inconsistent with the provider type/specialty (taxonomy).

So I called Utah Medicaid, and confirmed that 92025 is the code for corneal topography, and they confirmed that optometrists are not allowed to be paid for corneal topography because only physicians and hospitals are allowed to bill this procedure code. I pressed that optometrists manage conditions like keratoconus with corneal topography and that their policy definitely needs to be changed. The UT medicaid worker said she would bring it up at their meeting, but that meeting isn’t until next week, and she had several other issues that weren’t address at the last meeting.

So, I think she was telling me that she couldn’t guarantee that anything regarding my issue would be addressed in the near future. Even if they do discuss it sometime this month, they might not change their mind.

THIS IS COMPLETELY RIDICULOUS!!!. Hospitals? Hospitals can bill for corneal topography? How often do they do that? Can we name even one hospital that even owns a corneal topographer? The only physicians who use corneal topographers are ophthalmologists, but if I were a pediatrician they would allow me to bill for it?

Attention Utah Medicaid Taxonomy-Procedure-Provider-Type Committee: I hereby declare that you should immediately allow optometrists, provider type 31, to bill and be reimbursed for computerized cornea topography, CPT code 92025. Blue Cross allows it. I am trained to perform and analyze this test in optometry school. I need it to manage conditions like keratoconus, irregular astigmatism, pterygium, pellucid marginal degeneration, and transplanted cornea. All of these conditions I see in my practice.

Until now, I am willing to grant that the taxonomy/provider-type thing is an oversight- a snafu with the computer database. Now that this error has come to light, the only reason I can think that Utah Medicaid would continue in this erroneous policy is that the committee members making that decision are a bunch of anti-optometrist bigots. I don’t want to think that, so please reverse your policy as quickly as possible and allow optometrists to bill corneal topography.

I noticed the OfficeMate Knowledge Base had this update for us about certain CPT codes:

In the 2011 CPT Coding Manual, which is effective January 1, 2011, CPT code 92135 has been deleted and replaced with the following codes:

• 92132 – Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral (Replaces 0187T)
• 92133 – Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve
• 92134 – Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina

I like that because I hate having to remember modifiers like RT and LT, especially on tests that are most always run bilaterally anyway. I’m sure the insurance companies will like it for stats because it’s more descriptive by differentiating optic nerve vs. anterior segment vs. posterior segment.

UPDATE: Chuck Brownlow has more on this code change along with fiscal impacts.

Apparently it’s possible to take insurance without having to collect any copays or deductibles from patients. That’s news to me. Apparently Medicare and Medicaid have a waiver you can get to allow this scenario, but the article leads me to believe that with “private” insurances you can just drop the copay. Huh.

The libertarian in me thinks that ideally I should be able to collect or not collect with impunity, but I was sure current contractual agreements with “private” insurers required that I always collect.

(Note: I put quotes around “private” insurance since Obamacare effectively takes the free out of free enterprise.)