We always collected from the patient for a premium lens option with cataract surgery because it was considered elective and noncovered. Recently patients are requesting that we bill their Medicare Advantage (MA) plans for the specialty lens, stating it is covered. If we file, are we required to accept assignment even if the allowable is lower than what we historically collected? Are we able to state it is our office policy not to file claims for premium lenses?

Answer:
If you are a participating provider with the MA plan and they offer a premium lens benefit, then you are contractually obligated to file and accept their allowable. Although Medicare Part B does not cover premium lenses, some MA and other commercial plans do. Always verify benefits prior to providing service.

MLN907165 – Medicare Vision Services states, “For MA Plan patients, check with the MA Plan for information on eligibility, coverage, and payment. Each plan can have different out-of-pocket costs and specific rules for getting and billing services. You must follow the plan’s terms and conditions for payment.”

See also the “What About Other Payers?” section of Coding and Billing for Premium Lenses.