1 TearScience Reimbursement Program Frequently Asked QuestionsTearScience Annual Sales Meeting February 7-9, 2017 Presented by Syndi Burton, Reimbursement Specialist
2 Table of Contents Introduction New FAQ Document LipiScan Billing Tips Recommended Best Practices Q & A
3 Introduction to TearScience Reimbursement ProgramComplimentary service administered by Quorum Consulting Services provided to TearScience customers include: Payer medical policy research Billing and coding guidance Appeals for low-paid claims Predeterminations and prior authorizations Easy to enroll in the Reimbursement Program Sign a Business Associate Agreement with Quorum Ensures HIPAA compliance between Quorum and the site Complete an enrollment form Hours: Monday – Friday, 9:00 AM – 5:00 PM PST Tel: || Please Note: NEW FAX #!!! (NUMBER TBD)
4 New FAQs Document Features the top five of the most frequently asked questions that come in to the reimbursement program
5 New FAQs Document Question 1: Are the TearScience products and services covered by insurance? Usually not. Currently, most payers have either: specific medical policies that exclude LipiFlow and LipiView from coverage, because they are considered experimental or investigational, or umbrella policies that apply to all Category III CPT codes that are not covered. Category III procedure codes represent new and emerging medical technologies and services. In other cases, there is no specific policy, and the payer will conduct a medical review at the time of claim processing. The lack of a published coverage policy should not be equated with a negative coverage policy. It is recommended that providers check with a patient’s specific plan to determine coverage in advance of the treatment.
6 New FAQs Document Question 2: Can we collect the payment from the patient at the time of service? Patient billing and financial responsibility is something that can vary from payer to payer, and is heavily dependent on details such as contracts and provider network participation. Payers with provider networks (PPO, HMO, etc.) often have specific guidelines regarding patient billing for in-network, participating providers. We strongly recommend that providers check their provider handbook/manual, or get in touch with a provider relations contact, to confirm requirements or restrictions regarding patient billing and financial responsibility waivers (or ABN).
7 New FAQs Document Question 3: What CPT codes should be billed on the claim? The American Medical Association (AMA) advises that when billing CPT codes, providers should select the procedure code that most accurately identifies the service that was rendered, and do not select a CPT code that merely approximates the procedure, if a more specific code is available. Currently the procedure codes that most accurately identify the TearScience products are: LipiFlow : 0207T - Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral LipiView II: 0330T - Tear film imaging, unilateral or bilateral, with interpretation and report LipiScan/DMI: Unlisted procedure, eyelids NOTE: Ultimately, choosing which CPT codes to bill on a claim is the provider’s responsibility, and we should only be presenting them with their options, as opposed to giving them exact instructions.
8 New FAQs Document Question 4: Do we have to submit a claim?Maybe. Payer requirements regarding claim submission and patient billing are a contract issue between the provider and the payer. Payers with provider networks may require providers to submit claims for all services provided to the policyholder, regardless of coverage. Providers are encouraged to contact their provider relations representatives at the different plan networks that they participate in, and check contractual obligations regarding filing claims and patient billing. If in doubt, it’s best to have providers submit claims to ensure that they aren’t in breach of any contractual obligations.
9 New FAQs Document Question 5: How do we know if a payer is going to cover the procedure or not? Check payer medical policies online, or through provider portals. Contact a patient’s plan directly and request confirmation of coverage. Request a voluntary predetermination of coverage and benefits. When in doubt, the Reimbursement Program can assist enrolled sites with payer policy research, or requesting predeterminations/prior authorizations.
10 Billing for LipiScan 67999 - Unlisted procedure, eyelids.Currently, there are no existing procedure codes that specifically describe the LipiScan/Dynamic Meibomian Imaging procedure. The CPT procedure code that best describes LipiScan is: Unlisted procedure, eyelids. Sites can also use: Unlisted ophthalmological service or procedure. Providers should use caution if they want to bill External ocular photography. 92285 may be covered by payers if it is being used to track and monitor the progression of a disease over time. Payers often have a list of specific diagnosis codes that are considered allowable and billable with 92285 is not intended for use in a diagnostic setting, such as during a patient’s initial exam. Dry eye and blepharitis are not usually considered to be allowable diagnoses with
11 General Tips for Best PracticesBe truthful and not misleading, and make full disclosures to the payer about how a product or procedure has been used. This can help to protect providers from financial recoupments or penalties that can arise after an audit is conducted Conduct the due diligence research regarding claims, coverage and patient billing with payers, in advance of administering treatments to patients. This can prevent problems farther downstream such as refunding patients, and more serious ones like legal issues due to contract violations. Make sure that patient records contain accurate and detailed descriptions of the procedures and services provided. This facilitates fast and efficient processing of any claims that require the review of additional documentation, and in cases of low-paid claims, can greatly influence the outcome of an appeal. Sites should be encouraged to enroll in the Reimbursement Program, and can always contact us when any questions or problems arise.
12 NEW dedicated fax line:For any questions regarding payer medical policies, billing, reimbursement, or claim appeals for the TearScience family of products, please contact: TearScience Reimbursement Program Tel: TS-REIMB ( ) NEW dedicated fax line: (XXX) XXX-XXXX THANK YOU!