billable diagnoses for vision coverage under medicare

this is my job in a nutshell.  starting with an uncooperative optometrist's office, i sent an email to the state of nogero. i was not expecting anymore than a blow-off reply, which isn't far from what i got, but sometimes you have to keep pushing....

June 13 :: Email to OHA

I have a question regarding billing for vision coverage. I have encountered discrepancies among different optometrists billing departments.  Basically, what I am looking for is some kind of list of what are billable diagnoses that would allow someone to have an eye exam.

I have two clients with virtually the same age and health status, who are covered under OHP.  Neither had been to the eye doctor since 2009 (before the changes governing eye care occurred).  The main difference between the two is that one client has much worse eye sight.  That client cannot get his exam paid (according to the billing department of his eye doctor), while the other one did have his claim accepted last week (with the exception of the refraction fee).

The client who still needs to see the eye doctor has been told by the billing department that they cannot cover the exam fee unless he has a relevant medical diagnosis.  They called his PCP, who apparently told them he did not have any relevant diagnosis.  However, this client has been diagnosed with hypertension and seizure disorder as well as having developmental disabilities. 

Is this not enough?

When I called the other optometrist and asked their billing policies concerning the client who did have his exam fee covered, they said that all three of those things would have constituted a medical reason to have an eye exam and are covered by Medicare when they submit them.  I am trying to understand why one eye doctor will cover and one will not, when it seems a billing issue based upon an OHP policy.

June 17 :: Reply from OHA

There is no true list of diagnosis that would allow a member to get a sure fire payment on his vision claims. When it comes to denied exams claims processing problems may be to blame, there may be missing pieces in the members eligibility file, or there may be a misinterpretation of DMAP policy going on stopping the office from even billing out the claims. It is really hard to know without specific examples. I would like to take a look at the billing of the member that had his exam denied if at all possible.

Many things must be in place for a vision claim to process correctly, I wonder if you could give me something more to look into this so I can see the whole picture?

June 18 :: Reply to OHA

Thank you for the reply.

Here is what information I have at hand.

***** ********* ID #********** OHP Plus.

His PCP is **** ********. His eye doctor is ****** *******

I understand that he must pay a refraction fee and for any hardware, but his eye doctor has said that they cannot process the claim for the eye exam itself because he doesn't have a medical reason. However, he has developmental disabilities, hypertension, seizure disorder.  

If you need more information, please ask.

Thank you for your assistance. 

June 18 :: Reply from OHA

I was able to search his history and I see that it has been a long time since he has had an eye exam.

If his current clinic is unwilling to give him an exam, I would suggest that he visit another clinic.

I see that he is enrolled in a CCOB Eastern Oregon.  I would suggest calling them and asking why his clinic will not allow him to have an exam, and request a list of other clinics that he may go to for an exam.

June 19 :: Email to EOCCO

I left a voice mail with you earlier this morning, but cannot guarantee that I will be the person carrying my work phone at all times.  I have received advice from DMAP to contact CCOB Eastern Oregon for a client of mine who is enrolled in the program.  I must assume that means EOCCO?  If not, can you tell me who I would contact? 

The short version of the story is that this client was told by his eye doctor that he could not have his eye exam covered unless he has a medical diagnosis that necessitates an eye exam. He does have hypertension, seizure disorder, developmental disabilities and ADHD. They told me that none of those are sufficient reasons. However, another eye doctor in town, who is retiring and can't take new patients, just saw another of my clients two weeks ago and said that the hypertension, seizures and developmental disabilities are each reasons that they consider valid and have had these claims paid.

This client has been about 4 years since his last eye exam and since his vision is that good to begin with, it doesn't seem good for him to go that long.  He likely wouldn't be able to pay the full exam fee, especially if he needed to purchase new hardware on top of that.  I feel that if one doctor will cover it, then the other is giving me the run around.

When I posed this concern to DMAP, they pointed me in your direction to help find out either why his current eye doctor won't cover his eye exam or else to find another clinic would be willing to work with him.  Thank you for any help you can give me.

June 20
What I knew and learned about vision care:
$25 – vision refraction fee is not covered by Medicaid.  Hardware is also not covered. 
$125 is the approximate exam fee.  It is covered by Medicaid only if the participant is under 21 or is a pregnant female or unless they “have a medical need.”  What constitutes a medical need appears to be up to the PCP and/or eye doctor’s discretion, seeing as how one eye doctor said the same diagnoses are paid for them each time, while the other eye doctor said they are not acceptable. Concerned about these discrepancies, I contacted OHA/DMAP, who referred me to EOCCO.

Searching EOCCO, I saw only one name on the list and called **** ****** on Wednesday morning 6/19, received no reply, so I left an email that evening.  By Thursday morning, I had received two voice mails by agencies that my contact with ****** had been forwarded to.

First, a woman from EOCCO told me the following over the phone:

The case may require a referral to an ophthalmologist, rather than an optometrist. The ophthalmologist runs other tests along with the eye exam. That would be a way to have the exam done as long as the ophthalmologist is registered in-network with DMAP and MODA.  She thought the background was there, but he needs his PCP to make a referral.   She will track down an in-network provider and get back to me within a few days.  

Then a woman from MODA health called.

When I returned that call, I had to talk to someone else because it is a huge company (which Oregon has contracted out to take the place of ODS since this past May). That person told me that the man I called works for them, so he forwarded my message to them.  Presumably, the email I sent him was forwarded to EOCCO, though the woman at MODA was not sure why.  I explained to her that his name was the only one on the list for EOCCO.  She assured me that MODA was who I needed to contact in these matters, even though I told her the woman at EOCCO was in the process of assisting me already.  What I learned from her was very valuable and indicated even OHA had not been straight with me:

Both eye doctors in question are participants with MODA. To find which providers are in-network with MODA a search could be done on www.modahealth.com. Search for care, enter ID# and the site pulls up who is a participating member.  Somewhat helpful, though more helpful was information contradicting what the OHA person had said in my initial contact… A prioritized list as to what is funded is available on Medicaid website.   
http://www.oregon.gov/oha/healthplan/Pages/priorlist/main.aspx Click on “current prioritized list” and then click on a PDF of “prioritized list of health services.”   (Thankfully, I was taking notes!)   This is an exhaustive list meant primarily for providers that uses ICD codes to determine eligibility.  Depending on what diagnosis and procedure is meant to be done.  Higher than 498 will not covered, below 498 will be covered. (I assume she meant for adults with vision claims).  Anything not listed is also not covered.

While I awaited the return call from EOCCO, I looked up the ICD-9 codes for *****’s diagnoses:

Hypertension = 409.1

Seizure Disorders vary between epilepsy (345.9) and other convulsions (780.39)

Developmental disabilities (aka Pervasive Developmental Disorders) = 299.00-299.99

Unspecified Developmental Disability = 299.9 / Unspecified Intellectual Disability = 319

All mental disorders, including ADHD (314), range from between 290-319

The other client who had his claim processed had “amliopia” (code = 368.00)

Now I was really intrigued.  Basically, all the government agencies responsible for procuring providers and dispensing payment had told me that my client’s claim should be able to be processed. And every diagnosis seemed to be a qualifying factor.  However, the conversations I had with the PCP and the eye doctor indicated a heavy reluctance on their part.  It scarcely matters what any legal precedent is if the people directly involved in carrying out procedures won’t do it.  So, the issue pushed on…a couple weeks later.

July 2
I had not received a call back from EOCCO, but the MODA person did leave a message to say that ***** has relevant diagnoses and should be covered for a vision exam.  She tried to contact the PCP for a referral, but the office was closed for the week during the holiday.  Yes, the entire week!  I guess the message there is not to get sick during a major holiday.  The MODA person was able to leave a voice mail with the PCP.

July 10
The MODA representative still had not heard back from the person in charge of referrals, but assured me she was working on contacting them for a referral.

July 30
*****'s physician's office called to tell me that MODA had requested them to refer ***** for an eye exam.  It was to a different optometrist, but the expense is covered!   A success.  It only took a month and half and few headaches, but a success nonetheless.

Next time someone, even a person of authority, tells you something that doesn't quite make sense, do your homework and stand up for your rights.  Just a little bit of laziness and ambivalence on my part and my client would have either gone untreated or else ripped off.  And from the optometrist's point of view, listening and doing their homework might not have cost them a client.