Insurance Information

WILL YOUR MEDICAL INSURANCE COVER IT?
Dr. Johnson is considered an out of network provider. Dr. Johnson is not CONTRACTED with the insurance companies. Accepting their contract means that we would have to accept their rates for reimbursement and not “balance bill” the patient for the remainder. We can not provide advice on how this treatment may or may not fit into your particular medical insurance plan. We have learned a few things in the process and can share those observations mixed with some advice here.

In general, Medicare, Kaiser, HMO’s and others do not reimburse for this procedure. There may be a process, arbitration, etc., to allow for an out of network physician for this procedure, but it may be some work.

It is reasonable to try to find out if your insurance plan covers the laser treatment of vitreous degenerative disorders. Here are our recommendations:

• Call Member Services. Ask them if they cover the procedure code (CPT code 67031) performed in the office. They may also want Dr. Johnson’s corporation Federal ID number (EIN 26-4561133) or the Corporation’s NPI number (1891018206)
• Other Pertinent Codes: Your insurer may need to know the ICD Diagnosis codes.
  ICD-9 codes:
  379.21    Vitreous Separation, degenerative
  379.24    Vitreous Floaters
  368.10    Subjective Visual Disorder
   One or more of these are often applicable and one or more may be best to avoid. Your insurer may see “Vitreous Floaters” and say it is not covered, but a “Vitreous Degenerative Condition” is another matter altogether!!
• If they do, at what rate? They may be reluctant to give this information out, but be persistent or ask to be transferred to someone or a department that can give you this information. If they say, for instance, that they cover 70%, that is 70% of what? That 70% may be based on a “Usual & Customary” rate of only $300 and so the reimbursement will be much less than your expectation of 70% of my fees.
• Ask if you need pre-authorization. Because the CPT is a standard one, most will not need pre-authorization, but you may want to check first.
  Here are a few additional notes to bolster the argument that this is not a new or trivial procedure:

• The procedure is not experimental. It has been around for about 20 years
• The procedure uses a laser labeled for the use on vitreous (i.e., it is not an “off-label” use of the laser.
• Dr. Johnson is treating an abnormal condition of the eye. It is a partial and fluctuating opacity of the optical media.
• Sometimes, insurers will outright refuse to reimburse for treatment of eye floaters. Officially, we are treating a “Vitreous Degenerative Disorder”, a pathological eye condition.
• We have documentation that the major insurers have paid out and reimbursed for this procedure before (especially Blue Cross / Blue Shield / United Healthcare PPO’s to name a few). Since the precedent has already been established, they need to justify why they WOULDN’T reimburse for the same procedure for others.
• Please do not ask Dr. Johnson to call your insurance company on your behalf to gather or submit information. We experience the same difficulties when trying to call them and have to go through the same automated phone routing process. We do not have the staff to be able to accommodate your insurance processing requests.What seems like a simple request may take 2-3 phone calls and 20-30 minutes of frustrated effort.

Please do no use the comments section to leave personal contact information or detailed personal medical information. Keep it to comments, questions, or stories that will benefit other readers and floater sufferers. If you do have personal questions or requests, please go to the Email Dr. Johnson Page.