What to do when a Medicare Managed Care Plan changes rules on refraction
Diane E. Zucker, M.Ed., CCS-P
Health Care Management Consultant
In January 2022, Humana notified participating providers in a letter that identified refraction services (CPT code 92015 Determination of Refractive State) are considered bundled into the vision codes (92002, 92004, 92012 and 92014) and not payable separately by Humana or the patient. For traditional Medicare, the determination of the refractive state which is necessary for obtaining glasses and includes specification of lens type (monofocal, bifocal, other) lens power, axis, prism, absorptive factor, impact resistance and other factors is considered self-pay (as are most glasses and contact lenses). Under Traditional Medicare the determination of refractive state is statutorily excluded from coverage and is considered self- pay for the patient. The Humana process appears to hold the patient harmless (not financial responsible) for these charges based on the use of the “bundling” process.
What is a practice to do?
The Managed Medicare/Part C, products vary from traditional Medicare in a number of ways – they may limit their participating providers to a select provider panel; they may have services that require prior authorization or precertification; in vision care they may limit options for eyewear; the co-payments for specialty services are based on encounter/visit not based on the services charged and a flat dollar amount per visit; and other specific payment or claims processes that follow traditional Medicare guidelines but with a nuance that must be followed for payment of care provided.
The Medicare Advantage/ Part C plans are required to provide their policy holders with all the services and supplies that would have been provided under the standard Medicare Part A and B coverage. There are five levels of Medicare Advantage/Part C plans from the Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Private Fee for Service plans (PFFS), Special Needs Plans (SNP) and the Medicare Saving Account plans (MSA). These plan levels within a Medicare Advantage/Part C program have varied policies for the co-payments, prior authorization, precertification, referrals, payment of services, and some coverage parameters. The coverage parameters are usually specific to place of service(hospital, ASC, testing locations) and type of service for in-network care, out of network care, and emergency services. The Medicare Advantage/Part C plans must follow the Local Carrier Decisions (LCD) of our geographic area along with the overall traditional Medicare coverage scheme.
Since the refraction service is not covered by traditional Medicare how this service is managed by the Managed Medicare/Part C plans, appears to be problematic, specifically with Humana as the 92015 is now bundled into the related vision services for the same date of care. This new dynamic raises several questions for each practitioner seeing Humana Advantage/Part C patients.
Do I provide this service for “free” to Humana patients and take the “loss” just to maintain the Humana contract?
This is a financial decision that each practice needs to determine within their own structure and weigh the cost benefit of writing this off or not billing. This financial decision may impact the practice decision for future contracting with Humana, or any Managed Medicare/Part C plan that adopts this inclusion of services as part of the care process. Being paid appropriately for the work and care provided to patients is a reasonable expectation.
Can’t we just make the patient pay at the time of service as we do for traditional Medicare?
Based on the contract with Humana this service would not be considered a self-pay service as it is bundled into the vision services provided on the same date, and the patient would not be responsible. Collecting from the patient may a violation of the contract you have with the Part C Plan (Humana or others that may implement this bundling policy).
By collecting from the patient, you may have the contract terminated by the Medicare Advantage/Part C plan and have this identified as termination “with cause” that could be immediate in timing and impact your care if existing patients.
In providing a service for “free” that is statutorily excluded by traditional Medicare and requiring traditional Medicare patients to pay and other Part C covered patients to pay, is there a compliance concern we need to identify in our compliance plan?
Because this policy by Humana identifies it as a bundling edit policy (which is not supported by traditional Medicare CCI edits or the Optum Edits) one could reference in the billing section of your compliance plans that these specific write offs or unbilled services are permitted based on contract. (But check with your compliance Team and attorney to identify how best to oversee this).
If our practice decides to appeal this policy how do we proceed to challenge this bundling edit?
Challenging a Part C plan can be daunting because one first would need to go through the appeal process through in this case Humana with the identified documentation to support your rationale that this service should be covered or if not covered, under the same process as traditional Medicare, self-pay. These challenges to the Medicare Part C plan would need to be patient specific, so each denial of CPT code 92015 as bundled into the vision codes would need to follow the same appeal process.
Other options for the practice may be contact the local Medicare Part B Intermediary and seek their opinion on this policy and process and determine if this is appropriate in light of the CMS rules on coverage. If a portion of the patients covered by Humana are from an employer sponsored plan for retirees, discussion with the HR department of the employer and the role this may have for future contracting and the impact on their retiree’s health care may exert pressure on Humana to change their thought process. Informing patients of this inclusion and the fiscal impact it has on the practice may also be considered, though patients may not appreciate the fiscal impact of just “their” write off can create financial hardship to a practice, some may contact Humana as an advocate for your practice if they are concerned about your future participation with Humana. Letter writing campaigns to the Humana by providers individually and as a group, and include referral sources as part of this, may identify to their policy team the financial unfairness of this policy.
As Managed Care/Part C plans and other insurance programs look to reduce their payment obligations to physicians, it is important to monitor the policies, procedures and edits and be proactive when confronted with issues like this that expect services to be provided without fair compensation. As long as providers continue to sign contracts and follow these directives without vocalizing dissatisfaction, insurance plans will continue to enact them, at a cost to your practice.
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