Last August, I opened a new optometry office located inside a Walmart Vision Center. Our population is heavily Medicare and Medicaid, and we rely on medical billing for about 90% of our patients. A large number of our Medicare patients have Humana medical benefits and EyeMed vision coverage. With the current EyeMed reimbursement for Medicare Advantage patients at only $55, it is important to us that we bill the Humana medical plan for as many patient exams as possible.
Challenges with Humana Provider Networks
I was surprised when I reached out to Humana for credentialing, only to be informed by Humana Provider Relations that they had closed their networks to optometry and were not issuing any contracts for this specialty, which was not the news I had hoped for. Currently, we are in negotiations with Humana to become In-Network providers. In the meantime, we have been billing Humana using our patients' Out-of-Network benefits, which has proven quite successful. I'd like to share some tips on how to bill Humana Out-of-Network and still achieve better reimbursement than you would with EyeMed.
Key Steps to Effectively Bill Humana Out-of-Network
Verify Patient's Coverage: Before providing any out-of-network services, it's crucial to verify the patient's insurance coverage. Contact Humana's provider services or use services such as Availity, TriZetto, or Office Ally to confirm the patient's eligibility, benefits, and any out-of-network coverage limitations. This step will help you determine the patient's financial responsibility and set appropriate reimbursement expectations.
Pay Attention to Out-of-Network Benefits: When implementing these strategies, it's crucial to pay attention to the patient's out-of-network deductible. If the deductible is high, you might choose to bill the vision plan instead. Alternatively, for exams that are clearly medical in nature (e.g., for diabetes or cataracts), you can request that the patient pay out of pocket. In this scenario, you would still submit the claim to Humana, and the payment would count towards their deductible.
In the case of this patient, there was no deductible, co-insurance, or co-pay for either in network or out of network providers. This information was found on Availity.
Obtain Informed Consent: Inform the patient about your out-of-network status and the potential financial implications. Obtain their written consent, acknowledging their understanding of the potential higher costs associated with out-of-network services. This step ensures transparency and helps avoid any disputes later on.
Bill with Accurate Codes: When billing Humana for out-of-network services, it's important to use the correct billing codes. Ensure that you accurately document the services provided, including the diagnosis, procedures, and any relevant modifiers. Adhering to proper coding guidelines will help prevent claim denials or delays.
Submit a Clean Claim: To expedite the reimbursement process, submit a clean claim to Humana. Ensure that all required fields are completed accurately, including patient demographics, provider information, and service details. Double-check for any errors or omissions that could lead to claim rejections.
Consider Coordination of Benefits (COB) with EyeMed: If Humana denies the patient's refraction, you can submit the claim to EyeMed using COB. Some Humana plans are still eligible for EyeMed COB, except Humana Vision Insight and Humana Medicare. Follow the process of filing your claim with Humana first, then transferring the unpaid refraction to EyeMed using a CMS 1500 form.
Billing Patients for Unpaid Copays or Deductibles: Unlike VSP, EyeMed only pays for the refraction code. It's important not to routinely waive copays or deductibles owed by the patient, as this is considered insurance fraud.
Billing Instructions for Humana Claims
Submit your out-of-network claims either electronically with Payer ID 61101
or by mail on a CMS 1500 form to:
Humana Claims, P.O. Box 14601 Lexington, KY 40512-4601
Communication is Key
Effective communication with patients regarding the billing process is essential. Transparency builds trust and ensures patients understand the financial aspects of their care. Implementing these strategies can increase reimbursement for EyeMed/Humana patients, impacting your practice's bottom line. If you have any questions, feel free to reach out. I'm here to help!
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