Compliance Corner: Audit Defense: Building Your Internal Shield
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What is the overall purpose of the Compliance Corner episode on audit defense?
They can take care of all of my needs. I can take care of my optical needs and whatever they may be, you know, the spectacles, multifocals, you know, sun RX, contact lenses, plano sunglasses, whatever it may be, and still take care of all of my disease processes. That's the beauty of optometry. We really have exposure to the whole enchilada here. And yet we tend to put ourselves into small buckets and say, I can't do this on this visit because of this reason and this reason. That's just a bunch of crap. The bottom line is that when Mrs. Smith comes in, irrespective of who's paying for it, your job is to diagnose and treat everything that's wrong with that patient that's within the scope of your license.
So if she's myopic, astigmatic, presbyopic, has ocular surface disease and early signs of macular degeneration, you simply tell her, this is what we found. This is the best pathway forward for each one of those entities and be their doctor and take care of the entire patient.
So, John, we'll get into the episode in just a second, but I brought up with John, I wanted the audience to listen. I brought up with John the idea of what's happening in Nebraska right now, which is one of our major medical carriers have basically put a policy in that they're requiring prior authorizations on all optic nerve OCTs. And, and my ask to john was, why do you think they do that john like what what is the underlying mechanism? Is it they're just gambling that we're gonna or they're betting that we're gonna just not bill it or eat the eat the test? What do you think?
Yeah. So I think I mean, I think that they are absolutely betting on the fact that a certain percentage of the professional population will not either be aware of the rule or just not even want to go through the work that it takes to get it done for the reimbursement that they get, you know, varying between 28 bucks to, let's say, 38 bucks for OCT. And I think that they do the calculus and they say, look, if we get 25% of them that don't want to do the work, we save X number of dollars. I absolutely, I can't say I know for a fact, but I know for a fact that... These are all based upon utilization and what they're looking at is payouts over a given time period. This happened back with Anthem Blue Cross Blue Shield in 2017, 2018, when amniotic membranes just took off like crazy and everybody was doing an amniotic membrane.
Anthem Blue Cross Blue Shield simply came out and said, this is no longer a covered service that we do. This is now experimental and investigational. And they changed the classification. And it took about another year and a half, 18 months, to the best of my recollection, for them to now then re-evaluate that policy and then use name only products. So in this situation, they're, you know, requiring the PA understanding that People are just probably not going to take the, you know, did you say seven to 10 days in advance to be able to get it done?
Two to seven days. Yeah, two to seven days. And then it's unclear, but they are probably from the way they do existing PAs for amniotic membranes is that only lasts for a month. So it's not like if I were going to schedule that patient, I would know exactly when to schedule them. Or if I had ordered the test, let's say, six months ago or three months ago, that I could just, in our workflow, have them do the PA at that point because it's going to expire. Right. Yeah.
Yeah. So, okay. So
here's the, here's the battle back. Right. So I think you're right. I think in the first case, you know, this, this was policy. So NOA third party. So as, as the Nebraska Optometric Association's third party consultant, which practice performance partner is. And so the NOA third party update went out in June or July, making all members aware of that policy change. And so as of July 1st, that policy change occurred. And I mean, I'd love to say that we have this super high readership. I think we have a lot of readers, but people that actually take that to heart and think, I'm going to actually make a strategic change in my practice to anticipate this and build in place a protocol to manage it so that I can deliver the care I want to deliver my patients.
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Chapters
4 chapters
1
What is the overall purpose of the Compliance Corner episode on audit defense?
0:00–6:54
2
Why are Nebraska insurers requiring prior authorizations for optic nerve OCTs?
6:54–11:15
3
How do prior authorizations and ABNs affect clinical decision‑making for OCT testing?
11:15–18:33
4
What is the role of medical necessity and documentation in audit defense?
18:33–40:11
Speakers
1 identifiedMore from EyeCode Media
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