Progressive Focus© Newsletter
|Volume 2, Number 1||Spring, 2001|
|Helping You Manage the Expectations of Managed Vision Care|
What Makes One Managed Vision Care Plan "Better" Than Another? (Part 3)
In each issue of Progressive Focus© we've been discussing ways to differentiate vision plans by looking at issues impacting the quality of care you're able to provide. In issue number one we discussed your ability (freedom) to choose spectacle lens labs. Issue number two looked at covered spectacle lenses and frames, and the mandated use of specific brands. Here, in issue number three, we'll review some of the administrative issues that can make one vision plan better than another.
Dealing With Administrative "Hassles"
Dealing with managed care has never been easy for your staff. Verifying eligibility, checking benefits, collecting co-payments, submitting claims, reconciling explanation of benefits (EOB) reports --the list of time-consuming tasks goes on and on.
Your practice's ability to survive and grow under managed care is predicated in great part on whether your staff members go home at night looking to kiss their partners and kids or ready to kick their cats. If the day's frustrations have caused it to be the latter you're going to have serious problems maintaining morale and generating the levels of patient satisfaction necessary in today's highly competitive marketplace.
There's no question that vision plans differ greatly in the administrative hassle place on staff to process a patient through the system. While all plans represent that they're "user-friendly" and designed to make things quick and simple, reality tells us something quite different.
And though some vision plan managers do seem to consider office operations from the staff's perspective, others have created so many hoops to jump through that staff spends more time on non-revenue producing tasks (chasing paper) than on those that will grow the bottom line. Here, we'll look at a few, key questions and issues so that you can compare those plans in which you're now participating, and analyze any that you may be considering.
In comparing vision plans ask yourself "Do the protocols make life easy or hard for my staff"? And if there are complications, does the vision plan have systems in place to resolve them quickly and as painlessly as possible?
1) Eligibility Verification
a) Who is responsible for verifying eligibility, and when must that be done?
Does the plan mandate that your staff confirms eligibility for each service rendered? Does staff need to verify eligibility when the appointment is made and, possibly, re-verify eligibility prior to the date of service?
b) How is eligibility verified? By pre-printed form? By phone call? By on-line inquiry? And is an I.D. card enough?
Does the plan use technology effectively? Does it have systems in place to minimize inquiry time and to eliminate time wasted listening to "music on hold"?
c) What happens if the patient's name is not on the eligibility list?
Many plans do not do a good job updating their data bases with the most current information. A plan that frequently forces your staff to chase "current" information that should have been readily available will create a lot of frustration and office inefficiency.
d) What happens if eligibility is confirmed, but after providing services the patient is declared ineligible and your claim is rejected?
This is probably the most frustrating managed care issue -- and one that occurs too often. What is the plan's policy if you provide services based on an authorization that later turns out to be faulty? Will that plan "do the right thing" and pay you? Or will it tell you to chase the patient for payment?
e) Does the plan provide your staff with a dedicated contact person to resolve eligibility issues quickly and authoritatively?
If a plan's phone system defaults your call into a seemingly endless automated phone tree, or directs staff to a frequently asked questions (FAQ) section on the plan's website, that's going to create frustration and inefficiency. You need prompt access to a live person who can make decisions and resolve problems.
Did You Know...?
In 1998 optometrists reported that managed care had necessitated the following staff changes (% reporting):
- New staff hired to handle paperwork -- 36.2%
- Reallocated staff to handle paperwork -- 35.1%
- Delegated more tasks to technicians -- 40.4%
- Reduced staff to cut costs -- 6.4%
- Outsourced staff functions -- 4.8%
- No impact -- 29.3%
Source: Managed Vision Care Report --99/00,
Jobson Optical Group, pg. 9
2) Optical Benefits
a) Are the plan benefits, limitations, and exclusions clearly described in the literature supplied to patients? (And can you obtain copies of such documents?) Does the optical program provide a comprehensive exam and/or eyewear benefit covering the patient's true visual needs? Or is it a "bare-bones" benefit that's sure to put your staff face-to-face with disappointed and disillusioned patients?
All too often managed care patients will come to you under the impression that they're entitled to "free" glasses or contact lenses. Sometimes that's because they have not read the plan documents. Other times they have read the documents but they're so nebulous and/or misleading that it's no surprise patients have inflated and unrealistic expectations. Be sure that your staff knows what each plan is telling your patients.
b) Are those benefits, limitations, and exclusions clearly described in documents provided to your practice?
Since your staff will have to spend time explaining what is and is not covered it's essential that each plan provides you with complete documentation that can be shared with patients when necessary. If the plan can't or won't provide these documents beware, and be prepared for problems. It's absolutely essential that patients not leave your office thinking that they have been "scammed" or in some way denied their full benefits by an uninformed or mistaken member of your staff.
3) Claims Submission
a) Can (must) you submit claims electronically? If yes, can you do that without significant investment in new technology?
If available and utilized properly, electronic claims submission is an easy way to reduce claims submission errors and speed up payments. Unfortunately, however, some third party plans have implemented proprietary e-commerce systems that are anything but user-friendly. Some may even require substantial investment in equipment to access their data bases. And, interestingly, some plans actually will penalize you financially for submitting paper claims.
b) When documenting services can you use industry standard service codes or are you required to use codes unique to that vision plan?
While it's clear that every plan needs to track utilization in order to manage costs and measure overall performance, a plan's demands for non-standard data -- or minutia -- can sometimes place an extra burden on your staff. For example, you provide a fully covered frame and FT- 35 bifocals to a patient.
Plan "A" requires only that the claim form indicates bifocals, glass/CR-39 and covered frame. But Plan "B" requires that you indicate FT-35, that staff completes another box with a special numerical code designating the Rx power specific to bifocals, another with a numerical code to indicate glass/CR-39 specific to bifocals, and yet another box with a code indicating covered frame.
If you have these many customized codes in your computer and if it can complete the claim form, that's great. But if you're entering data manually (on either a computer or paper form) then these multiple fields and customized entries are potential sources of errors and claims processing delays.
Did You Know...?
Practitioners are embracing technology and filing electronic claims in rapidly increasing numbers. In 1997 and 1998 the three "Os" reported filing electronic claims as follows:
Source: Managed Vision Care Report '99/00,
Jobson Optical Group, pg. 22
News That Moves The Industry
Aetna, the nation's largest managed care company, recently announced that it was dropping its much despised "All-Products" clause from provider agreements. The clause requires providers to participate in all Aetna programs and plans if they are to see patients from any.
By requiring providers to participate in all Aetna programs and plans (and given Aetna's market share dominance in so many cities) the company could force doctors to accept patients from plans offering unacceptable reimbursements (or, perhaps, mandating capitation) in order to preserve access to patients from better paying and administratively less burdensome plans.
Those providers currently signed with Aetna will have 90 days prior to their contract anniversary dates to opt-out of existing "All Products" provisions (by sending appropriate written notice to Aetna). If a doctor does not file the appropriate opt-out notice then the provision remains in effect except in those few states that prohibit "All Products" provisions. New Aetna provider agreements will not contain the provision.
Diagnosing the Health of Your
Managed Vision Care Business
- Does staff track the average number of days in receivables for each of your vision plans?
- Does staff track the number of rejected claims by plan and the reasons for rejections?
- Does staff track the average profit per patient by vision plan?
- Does staff track the relative rate of inaccurate eligibility verification or the incidences of missing eligibility information by plan?
Vision Plan Profile
Vision Care, Incorporated (VCI)
To help providers and payers better understand the marketplace and players, Progressive Focus© will profile a vision plan in each issue. Here, we'll introduce VCI.
VCI started more than 25 years ago as a small, pre-paid vision care plan. But, under the direction of a group of managed care-savvy optometrists, VCI quickly became the largest pre-paid vision care plan in Florida.
Today, VCI's VisionCare Plan (an insured vision care product) has expanded into 17 states. A network of more than 9,000 providers serves more than 750,000 people throughout the U.S. Clients include major corporations, mid-sized and small employers, school and governmental entities, and labor unions.
But VCI is more than just a vision care plan. It also has a managed care division, Primary Plus, with 1 million members covered under an insured product and another 1.25 million covered under PPO/Access plans. Primary Plus provides total eye care carve-outs for vision and medical-surgical care through a joint ophthalmology/optometry network.
VCI (part of Comp Benefits Company which includes CompDent, a sister company providing pre-paid dental care to more than 2 million members) tailors vision products to different work environments and managed care entities including HMOs, PPOs, PHOs, and PSOs. VCI's clients consistently rate it as excellent, and the company's client retention rate (renewal) is 98%.
For more information about VCI or panel participation contact Howard Braverman, O.D., CEO or Peter Liane, O.D., COO at 800-749-5855 x192, or see the VCI website at www.visioncare.com
HIPAA, the Health Insurance Portability and Accountability Act, will have profound impact on how patient information is collected and transmitted, and protected and retained. Everyone, from solo practitioner to multi-state HMO will feel the effects. Here are some great sites to learn about what's coming down the road in the next few years.
The Electronic Healthcare Network Accreditation Commission. Learn about the various standards and how they were created.
The Department of Health and Human Services? site has all the rules and regulations.
HIPAA On-Line, an interactive tool on the HCFA site helps answer questions about health coverage and patient rights and protections under HIPAA.
These materials are intended to provide useful information about the subject matter covered. The author believes that the information is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation of the materials are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any type are disclaimed.
The materials are not intended as legal advice, nor is the author engaged in rendering legal services. The materials are not intended as a replacement for individual legal or professional advice. Information contained herein is presented only for illustrative purposes, and it should not be used to establish any fees or fee schedules, nor is it intended and it should not be construed as encouraging any user of the materials to take any actions that would violate any state or federal antitrust laws, tax laws, or Medicare or Medicaid laws.
Copyright © 2003-2007, Gil Weber, MBA. No part of this newsletter may be reproduced or distributed in any form whatsoever without the author’s prior written authorization.