Q4 2024 Newsletter
From the CEO
In the summer of 2023, four of us from PMRG (me, Donna, Paula and Jana) participated in a three-day retreat where we worked on what the retreat leaders called our BluPrint—and boy was it hard work! You have likely noticed a key piece from that work that shows our ultimate intent: creating the extraordinary, together. This is on the signature line of every one of our staff members’ emails.
In these three days, we created a Declaration of the Future and distinguished our core values. This work remains alive with us—we reference it almost daily and make sure how we conduct our business and interact with our clients (you!) and our vendors is consistent with what we have created. We acknowledge where we have fallen short, take responsibility for our mistakes, and celebrate where we are fulfilling our intent. Over the next several newsletters, I intend to share what we created with you and how it shapes our organization.
In this edition of our newsletter, I am sharing one aspect of the future we see and one of our core values. Understand that the future we see isn’t the truth or the way it is—we simply see it as a possibility, and one that we stand for and aspire to.
What we see is everyone involved in the process of medical reimbursement collaborating in partnership—a new model for doing business. When we say everyone involved in this arcane and cryptic world, we mean everyone! This includes the various vendors involved—from software to IT support to third party applications. It includes the insurers. And most obviously, it includes you, our clients!
This is consistent with one of our core values: partnership. When we say partnership, we mean this: we work together to fulfill common goals and intentions. We are aligned in purpose and vision. We are invested in the success of our team, our clients, and our key partners.
So we work from partnership with our eye on a future of collaboration, and—as our ultimate intent says—together. We hope this is evident to you in how we take care of your practice and how we interact with you and your staff. If you see us falling short of this, please let us know!
Curt Hill, CEO
PMRG, Inc
Clearing Up the Confusion
Around VSP COB Billing
by Jana Holt and Amber Van Vuren
Some of you may be aware that VSP Vision insurance offers a benefit for some of its members to allow providers to bill VSP as a secondary or tertiary insurance when the patient is seen for a medical condition. If you are not aware of this benefit, this article will explain when to use VSP as a secondary or tertiary insurance; how to bill it; and how to communicate this benefit effectively with patients.
When a patient is scheduled for a routine vision exam, and they have VSP as their vision insurance, an authorization should be obtained from VSP prior to the appointment. That authorization will indicate whether the patient has any exclusions on their plan that prevents you from COB billing. VSP has 12 different COB rules that may or may not apply. The one rule that staff should look out for is Rule 9: COB isn’t allowed. The other various rules were created for complicated billing scenarios, but they rarely apply.
If there are no exception rules that apply, the patient does have that benefit.
During the examination, if it is determined the patient needs to be evaluated for a medical condition, thus turning the vision exam into a medical exam, you can bill the secondary or tertiary “medical” insurance. Yearly diabetic exams are a great example of when an exam qualifies for both vision and medical COB billing.
Changing an exam from a vision exam to a medical exam can be confusing for patients. It is important to communicate the difference to your patient, and make them aware of the medical secondary or tertiary benefit they have with VSP. One way to effectively communicate this with the patient is to require the patient acknowledges this information with a signed document or consent (see resources below).
Once the exam is complete, and you have determined the exam was a medical exam, your billing team will bill the exam, refraction (if done) and any testing (if done) to the patient’s medical plan. Once the medical plan has processed the claim, your billing team will need to bill the exam and refraction (if done) only to VSP as the secondary or tertiary insurance. This can be done on VSP’s online portal through Eyefinity. VSP will process the claim as the secondary or tertiary payer and pay the provider according to the benefit provisions with the patient’s plan.
VSP offers many tools to assist the provider’s billing team to determine the benefits the patient has available, as well as the amount that VSP will cover as the secondary payer.
Below are several resources to help your office set up effective processes to maximize your reimbursement using VSP COB billing.
Additional Resources (Click to Download)
Employee Spotlight:
Michelle Prisco
This quarter we're excited to introduce you to Team Lead Michelle Prisco.
Michelle came to PMRG in 2018 after the company she worked for as a reimbursement manager for 10 years closed its doors. Her younger brother had just died--a devastating event for her entire family--and she wasn't sure what to do.
"I thought I would retire from there," she said.
One of Michelle's good friends suggested she interview for a job at PMRG as an entry-level biller, with the understanding that there would be plenty of opportunity to grow if Michelle wanted it.
"Since working at PMRG I have made many lifelong bonds with co-workers, even working remotely," Michelle said. "I am now a Team Lead, managing 13 practices, and I have six great billers that are part of my team."
Michelle is part of a big, very close Italian family.
"Family is very important to me," she says.
Michelle has two sons: Kristopher (21) and Vincent (19). She lives in St. John, Indiana and grew up in Chicago Heights, Illinois. Michelle is a big Chicago White Sox and Bears fan, and recently took up bingo and really enjoys it.
Thank you, Michelle, for being such an integral part of PMRG's team!
