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. 

a cold warrior turns

featured the past two weeks on the rabble rouser show...“a cold warrior turns” chapter one of  “jfk and the unspeakable: why died and why it matters” by james w. douglass

humanity reached a new age with the advent of nuclear weapons. harry truman loved the power of the a-bomb and the military industrial complex shared in his excitement. kennedy did not share in this vision, instead turning toward a vision of peace.  this became the notorious “nuclear dilemma,” the idea of destroying the world in order to save it from the evils of communism.  a series of maladies had plagued kennedy throughout his life, yet he maintained a youthful exuberance in his life and work. “you’ve got to live every day like it’s your last day on earth.  that’s what i’m doing.”  his own war experiences taught him what it felt like to be killed and he learned the preciousness of life, his own and those of his comrades.  in certain death during wwii, kennedy did not give up hope while he struggled to save the lives of his crew in the south pacific.

kennedy went into politics because it was the one arena where he could make the most difference in pushing the world toward peace.  even running for senate in 1946, his visions of peace were evident, “what we do now will shape the history of civilization for many years to come. we have a weary world trying to bind the wounds of a fierce struggle that is dire enough. what is infinitely far worse is that we have a world which has unleashed the terrible powers of atomic energy. we have a world capable of destroying itself. the days which lie ahead are most difficult ones, but above all, day and night, with every ounce of ingenuity and industry we possess, we must work for peace. we must not have another war.”

despite his goals of peace, kennedy did vote for and campaign for an arms build up to not allow a missile gap to develop. that is, until he learned that the u.s. was way ahead of the rest of the world in the arms race. kennedy became more committed to peace as his military commanders became more committed to crushing the enemy.  pushing things further, kennedy supported the algerian revolution, which brought disgust from virtually every american for “attacking the unity of NATO,” but which also made him loved in europe and africa.

that the power brokers were against kennedy seemed no surprise to him.  a note he had written once on the matter took abe lincoln to heart, saying that a storm was coming and he believed he was ready.  around the same time, he had been in a discussion about the book “seven days of may” with friends in which he said that a coup d' etat would not happen in washington on his watch, but that he knew a couple people who wished they could pull such a thing off.  kennedy pointed out that the conditions for such a change were possible, but would require precisely the right conditions. apparently, he offered up the correct conditions in his policy making...

first, was the botched bay of pigs invasion.  kennedy rejected the military plan, but the CIA went over is head anyway to try to pull him into a trap, thinking that when the turmoil got bad enough that he would have no choice but to give in and go along with a plan he didn’t agree with.  but as he said, “they had me figured all wrong.”   kennedy, of course, was heavily villainized after the failed attack that saw 1000 troops captured.  kennedy came unglued and said he wanted to “splinter the CIA into a thousand pieces and scatter it to the wind.”  he certainly tried by moving to cut their budget and reduce their military capabilities.  he had the director, allen dulles, and two deputy directors fired.  curiously enough, after JFK’s assassination, dulles was brought back and appointed by LBJ to direct the warren commission, an investigation that was pointed directly at himself!

second, JFK further alienated the CIA during the cuban missile crisis by ignoring requests from his joint chiefs for a pre-emptive strike.   in the media, kennedy played tough.  he demanded immediate withdrawal of the provocative soviet missiles and set up a naval quarantine of soviet ships getting into cuba.  kruschev’s own militant stand was based on castro’s warning that another bay of pigs was eminent, so kruschev sought to restrain u.s. forces while equalizing the balance of power that the u.s. had provoked by putting their own missiles in turkey.  kruschev said the missile placement was a direct response and that “now they would learn just what it feels like to have the missiles pointed at you.”  privately, however, kennedy was having secret correspondence with kruschev so as to be “free from the polemics of the cold war debate.”  kruschev duly did not wish for “backward glances from the press” and wanted to cast politics out the door without having them come back in the window.   they both impressed upon each other the need to find peace rather than try to win the last war on earth.  they both had the same dilemma of insiders pressuring them into acting, generals eager for a fight.  through their dialog, they agreed to a peace.  kruschev removed the cuban missiles and, in response, the u.s. removed their missiles from turkey six months later.   such trading was unorthodox politics and compromise was regarded as treason.  the joint chiefs saw the armistice as JFK’s lack of will.   they felt the need to strike first and quick and did not believe russia would have a reprisal to any attack.  kennedy’s response was that the military was mad and told his brother in another lincoln reference that “this is the night i should go to the theatre.”   bobby kennedy replied that, “if you go, i want to go with you.”

third, in the aftermath of the crisis, kennedy gave a speech at american university which was the mark of his turn away from the military’s imperialism toward peace.   he asked for a peace “not a pax americana peace…but a genuine peace.”   he disregarded the military industrial complex that was new in the american experience and held “total influence, political, economical, spiritual.”  kennedy told the graduating class in his speech that “we must guard against the acquisition of unwarranted influence whether sought or unsought by the military industrial complex.  the potential for misplaced power exists and will persist…self examination is the beginning of peace…a way out of the cold war and into a new human possibility.”

kennedy seemed to support the russian cause more than what would seem acceptable.  he asked “what about our own attitude that doesn’t get beyond ‘what about the russians?’”  he always advised people to not concern about the speck in your neighbors eye more than the log in your own.  he pitied the russians as having suffered more during wwii than any other civilization in history.  his feelings such as “when we feel the enemy’s pain...peace is necessary” were not taken well in the u.s.  on the contrary, however, the speech at american university was broadcast in the u.s.s.r. despite their history of jamming u.s. broadcasts.  within a year, they would stop jamming all broadcasts and even allow the atomic energy agency into the country for inspections.  kruschev hailed the speech as “the best from a u.s president since roosevelt.”  meanwhile, the u.s. media ignored the speech and didn’t promote it all.   in other words, kennedy’s speech more censored in the u.s. than it was in russia!

at the same time that kennedy was making enemies with the CIA and the military, the trappist monk thomas merton was upsetting his superiors by publishing works calling for peace.  he was reduced to writing to friends (in high places) about the suicidal moral evil of the inconceivable destruction of nuclear war.   the new warfare, and perhaps even wwii, he thought was based on affluence and big business.   the people were reduced to passivity, blinded by mass media, which served only to come up with slogans to “engineer consent,” making people unaware of the real situations and that problems were “nine tenths our own fabricated illusion.”  merton was not a believer in JFK initially and dreaded that he was “in a position so impossible as to be absurd.”  merton did not believe any one in government had the depth, humanity and totality to serve the greater good.  he thought the use of such destructive weapons force us into corners and we live by their powers.  “we excel at getting ourselves into situations where we have to push the button.” merton certainly had no faith in the military watching radar screens 24/7 for any sign of attack, noting “you know what happens when you keep your eyes fixed on something?  you begin to see things that aren’t there.”   merton came to believe kennedy really did have his heart in the right place, but consented that we “need special graces from god if humanity were to survive.”

the final part of chapter one looks at an ex-marine that would be used as a pawn as “an assassin in the making for years.”   lee harvey oswald had went to the u.s. embassy in moscow saying he wanted to renounce his u.s. citizenship and pledge allegiance to the u.s.s.r.    he said he would make known radar information he had obtained in his higher than top secret position in the marine corps.  he then went to work at a factory in minsk for a year before coming back to the u.s. to open arms by the state department.  he was given a loan and job, quickly issued a u.s. passport, and connected with many important anti-bolsheviks in the dallas area.  in other words, despite his supposed allegiance to the u.s.s.r., he was given prodigal son treatment by the u.s.    it turns out that the u.s. had sent many disenfranchised youths to russia to act as spies. oswald’s former roommate, james botelho – a future california judge – admitted as much and said that oswald had always been very anti-communist and suspected that he had been on an intelligence assignment. shortly after oswald’s “defection” the russians shot down a u2, rumored to be with information he had supplied.  however, in questioning for the warren report, neither oswald nor anyone connected with him, was ever asked anything about the u2 incident.  instead, the warren commission omitteed many facts and made oswald’s character look like a megalomaniac.

oswald was a pawn in a game that kennedy himself didn’t even believe in anymore.  kennedy was “turning faster than was safe for a cold world leader.”  kennedy pulled off a miraculous public campaign to get a test ban treaty supported within the u.s.   his rhetoric pictured 300,000,000 people killed in the opening exchanges and that “the survivors would envy the dead.”  JFK wanted to stop the arms race and was killed in 1963.   kruschev wanted to stop the arms race and was removed from power in 1964.  the cold war continued until the late 1980s and defense contractors profited accordingly.

to read more, check out the book, or tune in for the next chapter “kennedy, castro and the CIA” next week. for airing times, check back on the facebook page.