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AOA, affiliates pressure MAC to withdraw restrictive policy

November 21, 2012

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

“The federal law governing Medicare is 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., MPH. “With this action, we are hopeful that seniors 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.”

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

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 were 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 that 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, the AOA then appealed to pro-optometry lawmakers to help make clear to federal agency officials that states — not Medicare contactors — determine optometrists’ scope of practice.

The AOA and affiliates secured supportive letters from U.S. Sens. Pat Roberts (R-Kan.) and Jerry Moran (R-Kan.), and Reps. Bruce Braley (D-Iowa), Dave Loebsack (D-Iowa), Leonard Boswell (D-Iowa), Tom Latham (R-Iowa), Steve King (R-Iowa), Tim Huelskamp (R-Kan.), Lynn Jenkins (R-Kan.), Kevin Yoder (R-Kan.), Mike Pompeo (R-Kan.), and Michael Burgess, M.D. (R-Texas).

After building support on Capitol Hill, the AOA and affiliates then met with top Centers for Medicare & Medicaid Services (CMS) officials at the agency’s headquarters in Washington, D.C.

At the meeting, the 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 & Human Services’ Secretary Kathleen Sebelius responded to one of the lawmaker’s letters by acknowledging that the AOA and state representatives had demonstrated 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 to abandon its “optometry services” coverage determination, the precise action that AOA Federal Relations Committee Chair Roger Jordan, O.D., and state affiliate leaders had been seeking. WPS announced Oct. 2 that it would “retire” its optometry services LCDs.

To view the now-retired “optometry services” policies, follow the appropriate link for: Jurisdiction 5 (Iowa, Kansas, Missouri, and Nebraska) http://bit.ly/Tj2wMQ; Legacy States (Illinois, Minnesota, and Wisconsin) http://bit.ly/TYvBvy; and Jurisdiction 8 (Michigan, Indiana) http://bit.ly/PrKv0G.

The 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.

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