"Eye on Managed Care:  Old Headaches, New Headaches"

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"Eye on Managed Care:  Old Headaches, New Headaches"

More nasty surprises in the collateral documentation.

by Gil Weber, MBA
Consulting Editor

Adapted with permission from Ophthalmology Management
© Copyright, 2002. All rights reserved.
June 2002


Recently I received inquiries from practitioners asking me to review their managed care provider agreements and plan documents. I was struck by wording in some of the documents from these HMOs, vision plans and other third-party payers. Issues that seemingly fell out of favor years ago show up again. We'll examine a few of these in the first of this two-part article.

The same old song and dance

The following issues illustrate the importance of reading and understanding everything that a third-party payer sends to you -- not just the provider agreement.

Often collateral documents (provider manuals, frequently asked questions [FAQs], etc.) contain problematic provisions that you may not see before signing the provider agreement. Problematic policies, protocols and positions can affect your ability to participate profitably and comfortably in third-party care. Let's look at some examples.

From one vision plan's FAQ document:

Question: Can a member choose a frame that's not included in the (Name) Collection?

Answer: Yes. However, because the Collection is a large selection of frames with value for the member; was developed in a cost-contained, quality-focused format and was provided to you at no cost, we expect that selection outside the Collection will be minimal.

All the buzz-words are there: value, cost contained, quality focused. And the plan's literature describes how your practice will benefit by joining.

Of course, this plan expects a discount from the exam fee normally charged to your cash patients. And that's okay. The reason for discounting the fee is that you're supposed to get more patients and recover some of the discount on patient-elected frame and lens upgrad

Certainly, some practices work successfully with this type of managed vision care program. These practices have staffs who are skilled at identifying patient needs and cosmetic desires. They sell up to meet them. If it's done properly and professionally, there's nothing wrong with selling up.

Some plans facilitate selling up by giving your staff freedom to provide any frame a patient wants and allowing you to charge upgrades at the difference between usual and customary (U&C) and the frame allowance, or at a nominal discount from U&C, or at a viable, published upgrade schedule. With this plan, patients may choose any frame in your dispensary, but it's expected that they'll rarely go outside the plan's covered selection. It's implied that your staff should help the patients choose these frames only.

Why should anyone expect your staff to "default" patients toward a limited selection of covered frames on which there are no upgrade fees? It's an inefficient use of staff resources during frame selection and contributes little to the bottom line.

The plan would say you're not being ordered to direct patients to the covered frames, but you might reasonably perceive an implied risk if you don't. If many of the plan's enrollees pay out-of-pocket for non-covered frames, you might be perceived as an outlier and become a candidate for audit.

Directing patients

Another plan's provider manual states that the patient's benefit form will indicate if the patient is entitled to a frame and it will describe the patient's frame allowance. You should try to stay within this allowance when assisting the patient in selecting a frame.

This is even more specific. Again, why direct patients to the covered frames?

When evaluating a vision plan, ask yourself, "Can I justify participation based solely on the reimbursements for covered services and the assumption that many patients won't upgrade?" Upgrades are essential for survival in these vision plans, and I'd think carefully about any plan that tries to make upgrades rare exceptions.

Be vigilant

The return of these old headaches proves that you must be vigilant in managed care dealings. Aerosmith's tune, "It's the same old song and dance" keeps running through my head. Don't let it run through yours.


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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