AOA, state affiliates pressure Medicare contractor to withdraw restrictive policy

October 3, 2012

Facing intense pressure from AOA, state affiliates and pro-optometry leaders in Congress, a Medicare Administrative Contractor (MAC) reversed course on Monday and announced that it would withdraw a restrictive, anti-optometry coverage directive which wrongly sought to limit the scope of practice of optometrists in nine states.

Wisconsin Physician Services (WPS) — the MAC servicing Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska and Wisconsin — had issued an “optometry services” local coverage determination (LCD) whereby the contractor created a list of services it determined optometrists are allowed to provide based on its own flawed interpretation of state law. WPS then utilized the directive to deny payment for services provided to Medicare beneficiaries which optometrists are legally authorized to perform.

While Medicare LCDs are supposed to be based on clinical evidence, WPS developed and implemented this policy based on the personal views of one of its medical directors, often in consultation with ophthalmologists. Some states have been handcuffed for years by this WPS approach to define the scope of optometry practice with a narrow list of approved procedural codes.

When WPS extended the policy to more states in 2010, the AOA and state affiliates worked for two years to slowly convince WPS to make the list larger and more accurate, but by 2012 the limits of that relationship-building was reached when the Medicare regional office agreed with WPS that procedural codes defined as “surgery” by the American Medical Association (that is, all procedures) were theoretically outside the scope of practice of optometrists whose states laws forbid them to perform surgery.

Working closely with affected state affiliate volunteer leaders and staff, AOA appealed to pro-optometry lawmakers to help make clear to federal agency officials that states — not Medicare contactors — determine optometrists’ scope of practice. AOA and affiliates secured supportive letters from U.S. Senators Roberts (R-KS) and Moran (R-KS), and Reps. Braley (D-IA), Loebsack (D-IA), Boswell (D-IA), Latham (R-IA), King (R-IA), Huelskamp (R-KS), Jenkins (R-KS), Yoder (R-KS), Pompeo (R-KS), and Burgess, MD (R-TX).

After building support on Capitol Hill, AOA and affiliates then met with top Center for Medicare and Medicaid Services (CMS) officials at the agency’s headquarters in Washington, D.C. At the meeting, AOA and affiliates expressed concern that WPS has, as a matter of policy, substituted its own opinion about what constitutes the appropriate scope of practice of an optometrist, rather than deferring to interpretations of state scope of practice law by appropriate state authorities, such as legislatures, courts, and optometry boards.

Following the AOA-CMS meeting, U.S. Department of Health and Human Services’ Secretary Kathleen Sebelius responded to one lawmaker’s letter by acknowledging that AOA and state representatives had demonstrated that the WPS interpretation of state scope of practice was not correct. In the Aug. 29 letter, Secretary Sebelius stressed that the contractor must cover services “if those services are within the scope of practice as defined by state law and performed as defined by state law.”

With pressure generated through lawmaker outreach and the productive meeting with CMS leaders, the Medicare contractor had little choice but to abandon its “optometry services” coverage determination, the precise action which AOA Federal Relations Committee chair, Roger Jordan, O.D., and state affiliate leaders had been seeking. WPS announced on Tuesday that it would officially “retire” its “optometry services” LCDs.

To view the now-retired “optometry services” policies, please follow the link for: Jurisdiction 5 (Iowa, Kansas, Missouri, and Nebraska); Legacy States (Illinois, Minnesota, and Wisconsin); Jurisdiction 8 (Michigan, Indiana).

“The federal law governing Medicare is crystal clear in that it requires the program to cover services provided by doctors of optometry within state scopes of practice and gives Medicare beneficiaries the freedom to seek care from the doctor of their choosing,” said AOA President Ron Hopping, O.D.

“With this week’s action, we are hopeful that seniors in impacted states will no longer be improperly denied access to medically necessary, covered physician services that they need when they chose to legally obtain those services from optometrists rather than from other physicians,” added Dr. Hopping.

“While these developments are certainly a win for ODs and seniors in the affected states, it’s also a victory for optometrists and Medicare beneficiaries in states across the nation,” said Dr. Hopping. “If allowed to stand, these discriminatory policies and practices could very well have spread like wildfire across the country.”

AOA and affiliates will remain vigilant to ensure that any future policy developed by the contractor respects optometry and the right of Medicare beneficiaries to receive eye care through their optometrist.

AOA members with questions on this important topic and those looking to become more involved in federal advocacy should contact the AOA Washington office team at 800-365-2219 or ImpactWashingtonDC@aoa.org.

One comment

  1. Market-level analysis reveals that virtually all momentum for the program has been lost and that enrollment is shrinking back to the levels and locations found in the mid-1990s.

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