Progressive Focus©
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Progressive Focus© Newsletter

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Volume 5, Number 4 Winter, 2004
Helping You Manage the Expectations of Managed Vision Care

In This Issue:

Increasing Optometry's Access To Third Party Medical Eye Care Panels

In the third issue of Progressive Focus© for 2003 I discussed a just-entered Supreme Court decision regarding Kentucky's Any Willing Provider (AWP) law. And I speculated on the bearing that ruling might have on AWP around the country. It's an issue of particular importance to optometrists, and goes to the heart of the profession's relationship with key, third party payers.

The main AWP issue has always been the struggle between providers ready, willing, able, and qualified to participate vs. payers who, for whatever reasons, want to restrict panel admission. Obviously any practitioner denied admission to a third party panel loses access to that plan's patients and to the associated revenue flow. In some cities or states with market-dominating third party payers, being locked-out can have disastrous consequences for the doctor.

Medical Eye Care Panels: Locked Doors

In recent years, particularly in those states with weak or no AWP laws, one of optometry's most frustrating and vexing problems has been third party payers that simply refuse to admit ODs to medical eye care panels. No matter that state licensure may allow the OD to diagnose and treat certain medical conditions, or that Medicare pays ODs to provide certain medical eye care services, or that other payers may accept ODs to their medical eye care panels, these obstinate plans instead limit optometrists to providing only routine vision exams and eyewear.

OD attempts to join the medical eye care panels typically are rebuffed without a clinical justification that would disqualify an OD, and with no explanation other than a blanket statement: "We don't admit optometrists to that panel."

Changes In The Wind

Quotables

Nothing endures but change.

Heraclitus
Diogenes Laertius, Lives of Eminent Philosophers

AWP laws typically have been subject to a lot of interpretation. And it's clear that the protections written into the AWP laws of the seven states most directly impacted by the 2003 Supreme Court decision (Georgia, Idaho, Illinois, Indiana, Kentucky, Minnesota, Wyoming) do not necessarily extend to all of those states' practitioners. In some cases the protections apply only to physicians.

Of course, optometrists living elsewhere likely have no protection of any kind. Thus, recent events in Texas should be of interest to all ODs who may, to this point, have felt that they were tilting at windmills -- trying to break through a seemingly impenetrable barrier to medical eye care panel participation.

Texas enacted a law (effective September 2003) that will directly help that state's ODs who seek to join third party plans. And specifically in this case, it will help those who until now have been denied participation in third party medical eye care panels.

Texas SB857 changed Article 21.52D of the Insurance Code by amending one subsection and adding three more. The key elements ODs in other states want to note as possible guides for legislative efforts in the future include the following:

1) Medical panel was defined as ...health care practitioners who are listed as participating providers in a managed care plan or who a patient seeking diagnosis or treatment of a medical disease, disorder, or condition is encouraged or required to use under a managed care plan.

2) Vision panel was defined as ...the optometrists, therapeutic optometrists, and ophthalmologists who are listed as participating providers for routine eye examinations under a managed care plan or who a patient seeking a routine eye examination is encouraged or required to use under a managed care plan.

And then the new law addresses the heart of the matter for Texas ODs and those in other states who would hope to follow suit:

3) A managed care plan that provides or arranges for vision or medical eye care services or procedures must allow a therapeutic optometrist who is on one or more of the vision panels of the plan to be a fully participating provider on the plan's medical panels to the full extent of the therapeutic optometrist's license to practice therapeutic optometry.

The legislation also includes statements that a health plan may not:

  1. discriminate against a health care practitioner because the practitioner is a therapeutic optometrist,
  2. fail to include therapeutic optometrists as participating practitioners in the plan,
  3. restrict or discourage a participant from obtaining covered vision or medical eye care services or procedures from a participating therapeutic optometrist,
  4. fail to include the name of a participating therapeutic optometrist on a list of participating practitioners or fail to give equal prominence to the name,
  5. fail to include a therapeutic optometrist as a participating practitioner in the plan because the therapeutic optometrist does not have medical staff privileges at a hospital or at a particular hospital, or,
  6. fail to include a therapeutic optometrist as a participating practitioner in the plan because the services or procedures provided by the therapeutic optometrist may be provided by another type of practitioner.

Quotables

I pass with relief from the tossing sea of Cause and Theory to the firm ground of Result and Fact.

Winston Churchill
The Malakund Field Force

Terms And Conditions Of Participation

This certainly appears to be the more level playing field optometrists have been seeking for years. And Texas legislators have made a clear and unambiguous statement to health plans: You cannot blanket-exclude optometrists as medical eye care providers.

Note, however, that there are some caveats. The law applies only to managed care contracts between plans and Members (patients) entered into or renewed on or after January 1, 2004. Contracts in effect or renewed prior to January 1 continue under the "old" system. And the new legislation applies only to contracts between optometrists and third party payers entered into or renewed on or after January 1st.

Thus, there will be a gradual transition period as existing contracts expire/renew and as new contracts come into effect. So it won't be as if the floodgates are thrown open and medical eye care patients will suddenly stream into every practice. But over the next year or so there should be a clear and significant change in the relationship between many Texas ODs and certain third party payers, with a corresponding increase in the number of medical eye care patients coming into optometric practices.

Once ODs have satisfied a plan's credentialing process they'll be able to bill for the medical eye care services previously not allowed by those payers that have refused to consider the possibility that an OD might be qualified to ask more than "Which is better: 1 or 2?"

A One-Way Street Today; A Two-Way Street Tomorrow?

Texas' SB857 was written specifically to help optometrists. It does not benefit ophthalmologists. Its one-sided focus not withstanding however, SB857 is interesting for other changes it might generate in the future -- changes that could affect all eye care practitioners.

For example, SB857 as adopted does not work in reverse. It does not help a dispensing ophthalmologist who is now on a plan's medical eye care panel but who is precluded from simultaneous participation in the vision plan by an entity contracted to administer the vision panel. But it's conceivable such a situation could change in the future if SB857 proves to be as successful as its backers hope.

While SB857 as adopted will open many doors for optometrists -- providing patients more access to a larger number of practitioners -- ultimately it could create an interesting twist. If popular opinion shows that SB857 has been a great success for both practitioner and patient, that could initiate an effort to extend it to all eye doctors.

That would mean an amended SB857 (or a successor) could conceivably become a two-way street offering ophthalmologists the same rights to panel admission as optometrists. And then health plans and/or those who administer vision and medical eye care plans on their behalf would be obligated to open both panels to any qualified eye doctor.

That, hopefully, would mean a healthcare delivery system headed in a direction that ideally is embraced by all -- a system that emphasizes quality by documentation rather than quality by declaration. In such circumstances those who can demonstrate clinical competency combined with cost-effectiveness will be the ones attracting patients and building lasting relationships with payers.

Routine Vision Care Or Medical Eye Care?

Most ODs have found themselves in the middle of a frustrating situation when a patient presents with referral in hand from her Primary Care Physician. It's not uncommon for the patient's problem to have no relationship to the medical problem suspected by the PCP. Rather, all the patient needs to be made "visually happy" is a routine vision exam and refraction.

Caught Between Scylla And Charybdis

Unfortunately, when the patient does not have routine vision exam coverage it can all hit the fan when she is presented with your bill for full charges. The patient who had come in thinking her total financial responsibility might be a $15 co-payment for a medical office visit will not be at all happy to learn that the PCP's referral for medical eye care counts for nothing since the chief complaint was unrelated to any medical problem.

The bifurcation of routine vision care and medical eye care can and does cause all sorts of problems for patients as well as practices. Since there is an insurance premium component for each, it's simply a nightmare when the practice is caught between these two benefit programs that are distinct to the practice, but one and the same to the unknowing patient.

No matter how hard the staff or doctor might try to explain, the patient is never happy, and there may always be a lingering suspicion in the patient's mind that the practitioner is trying to "screw" the patient into paying for something that should be covered by insurance.

Quotables

"Then you should say what you mean," the March Hare went on. "I do," Alice hastily replied; "at least - at least I mean what I say - that's the same thing, you know."

Lewis Carroll
Alice's Adventures in Wonderland

What To Do When a Patient Presents For Routine Vision Care, But You Find Pathology

And there's a flip-side to that bifurcation, another all-too-common scenario that causes other headaches for patient and practice.

Mr. Jones schedules an appointment for a routine vision exam with refraction. But when he's in the chair you find a medical eye care condition. And suddenly there you are again, stuck in the middle of an absurdly complicated exercise in figuring out who gets billed for what - and when.

If the patient has presented for a routine vision exam and you find pathology, the manner and timing of your billings will be governed by what you do that day or will do later, and by various insurance plan rules. One thing for certain - you should not bill both the vision plan and major medical for an office visit/exam that same day.

Your initial billing should be coded and based on the chart documentation and reason the patient presented (chief complaint and primary diagnosis). In other words, if the patient came in for a routine exam and expressed no complaints but you found pathology, then you bill for the routine exam. If it's critical that the additional testing be done that same day then, depending on rules specific to the vision and major medical plans, you might be able to bill major medical separately, but only for your care related to the medical eye condition. In that case you would bill the vision plan for a refraction only.

To preclude any complications in the billing process some billing and coding experts recommend that you try to have the patient come back another day for testing specific to your medical findings. And then you would bill major medical for that encounter. If the patient can come back another day that's probably "cleanest."

However, how often is it convenient for a patient to come back, and how illogical must it seem to the patient who doesn't understand why you can't just do the other testing while he's in the chair, and send the bill to his insurance?

Whose Rules Do You Follow?

Who holds the master contracts, and who pays the bills? The old adage applies here: "Follow the money."

If your patient is insured for major medical and vision care through a single payer (e.g., VSP manages both routine vision and medical eye care for some health plans) then look to that entity for the rules regarding when and how to submit crossover vision care and medical eye care claims. In such instances things should be relatively straightforward since all claims and financial responsibility ultimately funnel through the same payment pipeline. You should not find yourself in a situation where two parties are sending you in circles, chasing your tail in search of payment.

However, in those instances where there is true bifurcation - for example the patient may have Aetna for (major) medical eye care, plus a routine vision plan contracted separately and directly by the patient's employer - then all bets are off.

Your staff will have to research to learn the submission and payment rules, and then figure out how to bill the respective entities only for those services for which it is responsible. Any incorrect billing and coding would be certain to result in a delayed or denied claim, and that would mean additional follow-up and resubmission work for the staff.

Update -- Latest Reports From Texas

The terms of SB857 are clear -- health plans are required to admit vision plan ODs to their medical eye care panels. And many optometrists are reporting success. However, others comment that certain health plans are reacting negatively to the obligations set forth in SB857. Apparently some Texas health plans are not yet on board with the legislature's marching orders.

Some ODs report being denied admission to the medical eye care panels with an excuse that "the panel is full." But SB857 does not appear to allow this as a reason to deny admission. There are also reports of health plans setting up "tiered" networks from which providers are being selectively disqualified.

It's possible that the bureaucracies within some insurance companies may not be getting the word out promptly to all employees. Certainly that should not be happening a year after SB857 was enacted, but some plan staff may be acting on out of date information -- simply unaware of the legislative changes.

The Texas Optometric Association (TOA) is working with health plans to inform them of the new law and its requirements. According to TOA payers are implementing the required changes as they're educated, plan by plan. But it's a slow go. As one OD told me "It's like trying to turn a big ship -- one degree at a time."

To help ODs the TOA has created a program through which Members can contract with it to take care of the credentialing and application process. TOA has added a full-time insurance consultant to work on Members' behalf, and has added specialized software to speed up the application process.

For the first three payer contracts TOA charges $895 per plan for this service, payable only if the OD is admitted to the medical eye care panel. The fee for a fourth payer or more is $595 per plan. A payment program is available on request.

Education is what you get when you read the fine print.

Experience is what you get when you don't.

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.

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.

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