When it comes to keratoconus (KC), the last thing you want to deal with is insurance issues. Many individuals often find themselves facing denials for either crosslinking (CXL) or contact lenses, both of which can cause serious financial setbacks. In hopes of alleviating some of your stress, we have put together this toolkit to help you navigate through any insurance issues you may be experiencing.
Insurance Tips For Cross-Linking
Your family member has recently been diagnosed with keratoconus (KC). Or, maybe, you’re the patient and you’ve known for some time that cross-linking is in your future. You’ve talked to your eye doctor about your options and decide to proceed with corneal crosslinking (CXL). What will this mean to your wallet?
CXL received FDA approval in 2016, and since that time, advocates including NKCF, patients, and eye doctors have sought to establish CXL as the standard of care for treatment of progressive KC.
As 2018 ends, 178 million Americans have insurance plans that include CXL as the accepted treatment for progressive KC. If you are covered by medical insurance (not vision plans like VSP or Davis Vision) your insurance company has done one of three things:
- Positive Coverage policy: Your insurer has published a policy describing the circumstances when they will pay for CXL. You can find that information by looking on your health plan’s website and searching under the key terms keratoconus or corneal crosslinking. Make note of any restrictions or necessary steps like prior authorization to make sure your claim will be paid. For instance, the doctor may need to show evidence of progression. In that case, the doctor may need to submit old records or take measurements of your cornea a few months apart in order to show that the disease is getting worse. The insurance plan may only cover CXL when the KC has progressed to a certain stage, or it may not cover CXL when the disease is considered too advanced to benefit from the treatment. The medical policy may be highly detailed or as simple as a sentence or two. If your insurance plan indicates it will cover the costs of CXL, and your eye doctor is a member of the plan’s physician network, your doctor cannot ask you to pay for the procedure out of pocket and cannot balance bill you the difference between what he or she is paid by the insurer and the amount of the claim. As a covered service, the doctor will submit a claim and will be paid directly by the insurer. Your obligation is only the co-pay or deductible that would apply to any similar procedure as determined by your policy.
- No Published policy: Although it is happening less and less, there are still insurance companies that have no written policy concerning corneal crosslinking. If you can’t find any mention of CXL in your insurer’s on-line medical policies, contact your employee benefits specialist (if you get your insurance through work) or call the health plan directly and speak with a representative. Remember, these insurance employees are taking inquiries for every possible type of medical procedure or treatment. They will likely not know about CXL off the top of their head. The representative may ask you for the CPT (Current Procedural Terminology) code. This is the code the doctor uses when submitting an insurance claim and may help the insurance plan employee locate policies or guidelines. The relevant billing code for collagen cross-linking including removal of the corneal epithelium is 0402T. If your insurance company has no written policy, your doctor may ask you to pay for CXL out of pocket, and together you can try to appeal to the insurer for reimbursement after the procedure. Make sure your doctor is willing to help you by filing a claim and appealing any denials. If your doctor is successful in getting the claim paid by your insurer, your doctor will return the money you paid in advance of the treatment.
- Negative Coverage policy: There are a few insurers that have written policies that specifically exclude coverage for corneal cross-linking. In that case, you will be expected to pay for the treatment out-of-pocket. You can still appeal to your insurance plan for an exception, but this will be an uphill struggle.
A pre-determination is a request made by the doctor to the insurance company, in advance of the procedure, asking if they are likely to cover the treatment. Especially for insurers that do not have a written policy, it is helpful for the doctor to receive an opinion before moving forward. A pre-determination request shows good faith on the part of the doctor to seek clarification of the status of a treatment plan. It will not assure that the doctor will be reimbursed, but a pre-determination letter from the insurer will help if the claim needs to be appealed. If an insurance plan sends a pre-determination letter that the procedure will not be covered, your doctor can ask you to pay in advance.
In some health plans, a pre-authorization or prior authorization may be required for procedures like CXL. This is different from a pre-determination opinion. If your plan requires pre-authorization, and your doctor does not get permission prior to treatment, the plan may not cover the services, no matter how medically necessary they are. Plans usually publish a list of procedures that require pre-authorization.
Because this is a relatively new procedure, your doctor may not have a lot of experience submitting CXL claims to your insurer. And even if the office has worked with your insurer in the past, coverage and medical policies are constantly changing. You can help by doing your homework- double check the details of your plan’s coverage and share this information with your doctor’s billing manager.
Finally, the billing CPT code 0402T refers only to epi-off CXL. If you and your doctor agree to epi-on CXL, or if you doctor wants to combine epi-off CXL with other procedures like Intacs or vision correction surgery, that billing code does not apply. In any situation outside of the FDA- approved epi-off protocol, expect to pay out-of-pocket without any assistance from your insurer.
Steps to Appeal Denied Claim
