WILL YOUR MEDICAL INSURANCE COVER IT?

Dr. Johnson’s practice does not accept medical insurance for payment of services and he is considered an “out of network” provider. Dr. Johnson is not contracted with the insurance companies. We can not provide advice on how this treatment may or may not fit into your particular medical insurance plan. That said, you may still be able to get partially or fully reimbursed for the procedure. Generally, Dr. Johnson will provide patients with a detailed receipt which includes dates of service, diagnosis and treatment codes, and what has already been paid by the patient. The patient can submit a claim independently with this receipt. Your insurance web site or customer service representative should be able to help you get a claim form specific to your insurer. We have learned a few other things about this process and can share those observations mixed with some advice here.

COMMERCIAL INSURANCE INFORMATION

FOR COMMERCIAL INSURANCE PPO’s (e.g. BLUE CROSS / BLUE SHIELD, UNITED HEALTHCARE, CIGNA, ETC:
It is reasonable to try to find out if your insurance plan covers the laser treatment of vitreous degenerative disorders. Here are our recommendations:

  • Call Member Services. Ask them if they cover the procedure codes listed just below. (CPT code 67031*) Procedures are performed “in the office” (not at a surgical center or hospital). They may also want Dr. Johnson’s corporation Federal ID number (EIN 26-4561133) or the Corporation’s NPI number (1891018206)
  • Pertinent Insurance Codes: Your insurer may need to know the CPT (procedure codes) or the ICD Diagnosis codes.
    Common Procedural Terminology (CPT)
    67031     Severing of vitreous strands, vitreous face adhesions, sheets, membranes, or opacities, laser surgery
    ICD-10 DIAGNOSIS codes:
    H43.311 Vitreous Membranes/Strands- RIGHT EYE
    H43.312 Vitreous Membranes/Strands- LEFT EYE
    H43.313 Vitreous Membranes/Strands- BOTH EYES
    H43.811 Vitreous Degeneration – RIGHT EYE
    H43.812 Vitreous Degeneration – LEFT EYE
    H43.813 Vitreous Degeneration – BOTH EYES

  • Your insurance provider says it is a covered procedure, but at what rate? They may be reluctant to give this information out, but be persistent or ask to be transferred to someone or a department that can give you this information. If they say, for instance, that they cover 70%, that is 70% of what? That 70% may be based on their arbitrary “Usual & Customary” rate of only $300 and so the reimbursement will be much less.
  • Ask if you need pre-authorization. Because the CPT is a standard one, most will not need pre-authorization, but you may want to check first.
  • We can not call your insurance company on your behalf for pre-authorization if you have not had an exam with Dr. Johnson.

MEDICARE RECIPIENT INFORMATION:

Dr. Johnson has opted out of the Medicare program. We have submitted an affidavit with the Medicare program attesting that we will not submit any claims to their program. As such, if you are over the age of 65 and a Medicare beneficiary, there are some special considerations that apply:

  • The patient will be entering into a private contract with Dr. Johnson and Vitreous Floater Solutions.
  • Patient agrees not to submit a claim (or to request that Physician submit a claim) to the Medicare program with respect to the Services, even if covered by Medicare Part B.
  • Patient acknowledges that neither Medicare’s fee limitations nor any other Medicare reimbursement regulations apply to charges for the Services.
  • Patient acknowledges that Medi-Gap plans will not provide payment or reimbursement for the Services because payment is not made under the Medicare program, and other supplemental insurance plans may likewise deny reimbursement.
  • Patient acknowledges that he has a right, as a Medicare beneficiary, to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare, and that the patient is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out.
  • Patient agrees to be responsible to make payment in full for the services, and acknowledges that physician will not submit a Medicare claim for the services and that no Medicare reimbursement will be provided.
  • Patient understands that Medicare payment will not be made for any items or services furnished by the physician that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim were submitted.

 

* From the American Medical Association, Common Procedural Terminology (CPT) codebook. The CPT code set was designated by the department of health and human services  as the national coding standard for physician and other health care professional services under the Health Insurance Portability and Accountability Act (HIPAA). For all financial and administrative health care transactions sent electronically, the CPT code set will be used. The CPT codebook is the most widely accepted nomenclature for the reporting of physician procedures and services under government and private health insurance programs.
 

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