Traditional Medicare vs. Corporate Vision Insurance

December 15, 2011


Optometrists should be vigilant to preserve the Medicare third-party model as we negotiate with vision insurers for contracts that are fair to all concerned. Whereas medical insurers typically recognize Medicare as the third-party model, some vision insurers are modifying the Medicare model for their own purposes. Because these corporate giants primarily recruit ODs as their vision providers, optometrists are effectively segregated from the majority of medical eye providers who do not also serve as vision providers. Therein lies a grave threat to optometry. As vision insurance is expanded to include medical eye coverage, optometrists contracted to provide services for combined vision and medical eye policies will likely lose parity on medical eye services with non-contracted ophthalmologists and all other medical eye providers.

In 2010, a major insurer began offering routine vision plans in which fundus photography is an optional benefit. With little provider attention, this insurer actually re-defined code 92250 (i.e., fundus photography) referring to it as a “retinal screening” and assigned a fee for the technical component without regard to the professional component. This contradicts the 2011 “AMA CPT Professional Edition,” which describes code 92250 as “Fundus Photography with interpretation and report” and requiring medical necessity. Redefining of code 92550 as a “Routine Retinal Screening” may seem to be a positive change. However, such vision policies in our area rarely, if ever, reimburse for “Routine Fundus Photography,” and most patients understandably reject a special medical test without medical necessity.

In addition to redefining code 92250, the vision insurer claims that the “modifier-52” should be used “to identify and separate the routine covered service from the medical service.”  According to the 2011 “AMA CPT Professional Edition,” the modifier-52 is for “reduced services.” It is not intended to describe what the vision plan refers to as “routine” services. Again, this insurer sets a combined vision and medical eye policy precedent as it redefines a Medicare modifier that is explicitly described in the 2011 “CPT Professional Edition.” In 2011, a second major vision insurer announced that “retinal imaging is another important component of our wellness program…a funded benefit, with or without copay, or as a fixed member discount through in-network providers.” With many of these policies, ODs are now expected to discount a special medical test (i.e., fundus photography) for which the vision insurer typically reimburses nothing. Under these circumstances, optometrists lose parity with all medical eye providers who are not also contracted vision providers.

As Medicare continues to move toward insolvency, privatization in whole or in part may be the result. If so, can such vision/medical insurers be trusted to help maintain the Medicare third-party model that has been instrumental in providing parity among providers? If so, why are such corporations already redefining special medical test coding? Why are they determining what special medical tests the OD can/cannot perform?  Aren’t vision insurer modifications to the Medicare third-party model more beneficial to the insurers themselves than the patient?

When corporate vision insurers dominate and control the market in a particular area, competition is stifled and ODs often have little choice but to sign as a provider. Otherwise, the OD risks loss of an existing and/or potential patient base.  The threat of such control over optometry is magnified as these insurers redefine the Medicare third-party model to combine vision and special medical testing.

Optometrists fought desperately to become more than just providers for Medicare; we sought all the rights and privileges afforded under the concept of the third-party Medicare model. Many ODs will never forget the hard-fought battles with insurers to become providers of medical eye care and to gain parity among providers utilizing the Medicare third-party model as our guide. Now, we are witnessing a dismantling of the Medicare model by some vision insurers who are effectively creating a new third-party model unique to optometry.

Don’t optometrists have a responsibility to help maintain the Medicare third-party model? We can begin as follows:

1. Support the AOA
a. Keep the AOA informed of third-party grievances with insurers
b. Seek AOA assistance in lawfully and effectively evaluating third-party insurers

2. The third-party chair in every state should seek legal assistance to monitor all third-party insurers. They should ask to review all types of insurer contracts being offered to potential OD providers, and these should at least be assessed for legality, uniformity of guidelines, parity among providers, and fairness to prospective patients and providers. Contracts with insurers should never interfere with the OD’s incentive to provide optimal care to the patient. The state third-party chair should compile the results for ODs in their state associations to review prior to discussions with insurers. These evaluations should be updated yearly. If third-party insurers are not cooperative with such evaluations, the state associations should inform their members. According to the Mississippi Attorney General’s Office, there is no anti-trust violation in seeking legal assistance to properly evaluate third-party insurers. Remember, insurers typically evaluate providers very carefully initially and annually. It is we (ODs) who falter in evaluating the insurers before and after signing detailed contracts that are often misunderstood.

3. Optometry should deal with third-party insurers with the same efforts and fortitude that we have demonstrated in the legislative arena. When-ever some ODs are forced to resort to legal action against third-party insurers, all ODs should assist in the battle.

In conclusion, optometry is threatened with grave third-party challenges as just discussed. For the sake of our patients and profession, we must work harder than ever to resolve the following:

1. Vision insurer attempts to segregate optometrists as providers for combined vision and medical eye policies
2. Dismantling of the Medicare third-party model
3. Replacement of the Medicare model with a new third-party model unique to optometry
4. Third-party insurer control over optometric practices
5. All threats to parity with other medical eye providers
 These are some of the greatest challenges ever faced by optometry, but we can and must prevail.

Lawrence A. Routt, O.D.
Kosciusko, Miss.

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