Insurance & Billing

Will insurance and Medicare pay for in-office cataract surgery?

For more information, see our short informational video regarding insurance reimbursement for in office surgery.

That’s a more complicated answer than you might think. In general, for procedures like cataract surgery, the answer is no – unless you have special agreements in place.

 Traditional Medicare and Medicaid agreements are non-negotiable (you cannot negotiate special agreements) and they have no ‘place of service’ differential to pay for in-office cataract surgery. If you charge traditional Medicare or Medicaid (including traditional Medicare plus supplemental insurance) a facility fee or facility fee copay for in-office cataract surgery – that’s fraud. This is true for all insurance companies unless you have special agreements in place. And that’s where we come in.

We don’t want you to commit fraud, and we want you to get paid well! We have over 20 agreements that include all types of insurance plans (Medicare Advantage, Commercial, Health Insurance Exchange, Managed Medicaid, and Agency) that you can join  that pay out on par with ASCs.

How does billing work for in-office surgery?

It can be complicated…

And that’s why we take care of the billing process for you. We work with a team of revenue cycle management experts with extensive in-office (particularly ophthalmic) surgery experience. We handle the process from end-to-end: prior authorization, determining patient responsibility, claim submission, appeals, and special agreement renegotiation. Our goal is to completely handle billing for you – and remember, if you don’t get paid, we don’t get paid!

In-office surgery billing is especially arduous when it involves special insurance agreements like the ones we’ve arranged (that give you additional reimbursement).

This is true for multiple reasons, including:

  • Agreements vary in how payment is arranged (i.e., which insurance department pays, which codes are used for billing, which ‘place of service’ code is used, etc)
  • Ensuring that the insurance company pays properly can be difficult (as these are special agreements and typically require special operations in the insurance companies’ claims processing systems)
  • Obtaining assistance when claims aren’t paid properly can be tedious:
      • The department that created the special agreements is separate from the department that operationally sets up the agreements to properly process and pay.
      • A third (entirely separate) department handles appeals.
      • Navigating whose help is needed, how to find the representative needed, and getting their attention can be overwhelming as many barriers are in place.

      But remember – we’re already doing this successfully. We handle this so you don’t have to!