"Eye on Managed Care: More Vision Plan Woes"

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"Eye on Managed Care: More Vision Plan Woes"

Often times you'll find nasty surprises in the Provider Manual.

by Gil Weber, MBA
Consulting Editor

Adapted with permission from Optometric Management
© Copyright, 2002. All rights reserved.
July 2002


Last month I discussed how issues I encountered many years ago- ones that had seemingly fallen out of favor with third-party plans - are showing up again. Here are some more examples, and what you need to watch out for to make sound decisions about whether to participate in a given insurance plan.

Hidden agendas

The vision plan documents doctors sent me after my practice management lectures about insurance plans contained other troubling issues. Sometimes it's a bit difficult to understand the nature of a problem when it's wrapped within an obtuse paragraph. Take this, for instance.

From one vision plan's provider manual:

Filing fees: According to the (plan name) Panel Agreement, your payable fees may be reduced if it's determined that you're receiving lower fees than those accepted from (plan name). The determination to lower your fees may come from several sources, including: quality improvement reviews, telephone surveys, advertisements or acceptance of lower fees from other vision care plans.

Did you catch it? This is the infamous "most favored nation" clause, back again.

This clause says that if you sign a provider agreement containing a "most favored nation" provision and have previously accepted or in the future accept lower fees from another vision plan, you can be required to amend this new contract to match those lower fees paid by another plan. That "trap" precludes your ability to selectively negotiate fees based on your determination of a plan's value to your practice.

Say you're offered a deal to receive $38 for an exam from Plan "A." You might have an existing agreement with Plan "B" paying $44 for the same service. Assume that Plan "B" has a most favored nation clause in its provider agreement.

Is Plan "B's" deal paying $6 more a better deal than "A's"? What if "A" pays consistently in 14 days, while "B" consistently takes 45 to 60 days? What if "A's" administrative protocols are simple, while "B's" leave your staff frustrated at the hoops they have to jump through? Which deal is better in its entirety?

Wouldn't you want the freedom to take "A's" lower fees because you'll get paid faster and your staff will have less hassle? Might that make a lower reimbursement worth considering?

But if "B's" provider agreement contains a most favored nation clause, you have to give it the lower fees paid by "A" and take the slow payments and hassle. Your freedom to negotiate with other payers is stripped away.

And consider this nasty surprise. Assume you signed a deal with "A" three years ago paying $38 for an exam. You sign a deal with "B" paying $44, and a few months later "B" finds out about the old deal. Now "B" can demand that you match the lower fee even though that rate is 3 years old and may not make sense now. A most favored nation clause can obligate you to accept the nonviable reimbursement from "B."

And from another vision plan's provider manual:

Quality improvement program - In-office reviews: Each review has the following objectives:

Confirm that the doctor's examination records for randomly selected private (non-plan name) patients are receiving the same level of examination and quality of care as (plan name) patients.

This old-time plan protocol could put your practice at significant risk. Here's why it's dangerous.

You know that protecting a patient's privacy and medical records is one of your most important duties. The penalties for failing to do so can be significant. And with the new government regulations under the Health Insurance Portability and Accountability Act umbrella, they're going to get tougher for those who fail to comply.

Involuntary violation

The provider manual's provision would make you violate that privacy by affording a vision plan's auditor access to confidential records. You can't allow any vision plan to audit the records of patients who aren't participants in that plan.

Despite what their protocols may say, vision plans don't have a right to inspect any patient records except those of their members, and then only with the patient's permission. Note: that permission may have been given when the patient first signed up for the vision plan, but your private-pay patients certainly haven't given such authorization.

This is why it's important to have qualified counsel review plan documents and help you revise or remove language that could put your practice at risk.


Gil Weber is an author, lecturer and practice management consultant to the managed care and ophthalmic industries. He has served as Managed Care Director for the American Academy of Ophthalmology.

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