Reform placing new importance on evaluating insurance plan participation

December 27, 2012

Identifying the insurance plans through which patients are most likely to obtain eye care coverage, applying to health plan provider panels, and evaluating health plan provider contracts are about to take on renewed importance, according to the AOA Third Party Center.

The Affordable Care Act (ACA), better known as the federal health care reform law, could soon offer optometrists the opportunity to provide care for millions of currently uninsured Americans who will obtain health insurance under provisions of the law.

Also, a landmark provider-nondiscrimination provision in the health reform law is expected to level the playing field for optometrists contracting with existing health plans – including the employer-based insurance programs through which many Americans obtain health care coverage, according to Stephen M. Montaquila, O.D., AOA Third Party Center Executive Committee chair.

The ACA’s Harkin Amendment – a new health care provider nondiscrimination provision that goes into effect in 2014 – bars insurance plans from discriminating against any health care provider who is acting within the scope of that provider’s license or certification under applicable state law, with respect to participation under a plan or coverage.

The provision gives optometrists a new tool to gain inclusion as providers of both eye and vision care under new insurance plans to be offered through state health insurance exchanges beginning in 2014, as well as variety of non-exchange insurance plans.

The long-sought provider non-discrimination provision also applies to existing insurance programs. And for the first time ever, employer-based plans organized under the federal Employee Retirement Income and Security Act (ERISA) will have to comply with a national provider non-discrimination law.

ERISA plans have long claimed exemption from state provider-nondiscrimination laws and have often arbitrarily excluded optometrists from their provider panels.

Even before the new federal provider nondiscrimination provision becomes effective, Fortune 500 companies (see “Chrysler workers gain coverage for OD medical eye care,” AOA News, April) and major regional employers (See “Health system in Maryland to cover OD eye care for employers,” AOA News, August) alike have already begun to open their health plan provider panels up to optometrists as providers of primary eye care, the AOA Third Party Center noted.

More will likely follow suit in the coming months, and the pace will pick up once the ACA is implemented, according to Dr. Montaquila.

“The enactment of the Harkin Amendment provides optometrists a unique opportunity to approach health insurance administrators and explain that participation by optometrists on their major medical plan provider panels is not only in line with the new federal law but can improve cost-efficiency and patient outcomes by enhancing access to preventive care and providing an alternative to expensive emergency room care,” Dr. Montaquila said.

The AOA Third Party Center suggested optometrists keep abreast of the plans for developing health insurance exchanges in their areas.

Dr. Montaquila suggested they should also review the local health insurance market to see whether they are now able to participate on provider panels for all employer-based plans or other private-sector insurance plans, allowing them to properly serve their patients.

AOA members may also wish to review guidance offered by the association on strategies for approaching health care plans about the inclusion of optometric eye care.

As new health exchange insurance programs become available, and existing major medical plans are opened to optometrists, practitioners will need to properly evaluate provider participation contracts and fee schedules.

Dr. Montaquila suggested practitioners now review available AOA resources.

Identifying plans

A recent White House document, “2012 Progress Report: States are Implementing Health Reform,” assessed the development of state health insurance exchanges across the nation.
The U.S. Department of Health & Human Services (HHS) offers further information regarding the establishment of health insurance exchanges at (www.healthcare.gov/law/resources/index.html) and (www.healthcare.gov/law/features/choices/exchanges/index.html).

Practitioners can check the HHS website or similar resources to stay abreast of health insurance exchange development in their states.

Most practicing optometrists are probably familiar with the major medical plans offered by the employers in their areas – and know whether they currently cover medical eye care services provided by optometrists.

However, even if optometrists were not able to file medical eye care claims with those plans in the past, now may be good time to approach health plans and administrators about covering eye care provided by optometrists.

Practitioners can review the insurance programs of local employers to see if they have switched carriers.

Staff may assist in conducting surveys of various insurance plans through which patients (or potential patients calling the office) have medical coverage.

If patients are being redirected because the practice does not accept a popular medical plan, it may be time to consider becoming a provider for that plan.

Approaching plans

Once optometrists have identified an insurance plan under which they wish to provide eye care, the AOA Third Party Committee and affiliate third-party chairs can provide an outlined process for approaching the plan, including identification of key decision-makers such as:

  • human resource executives
  • third-party administrators (used by many employer-based plans)
  • Medical directors, and
  • benefits committees.

The AOA Third Party Committee can suggest wording for letters to plan administrators, providing information on the Harkin Amendment and the advantages of medical eye care provided by optometrists. The committee can also offer tips on scheduling a meeting with plan administrators.

Once a meeting has been scheduled, the AOA Third Party Committee can provide detailed information for presentation to plan administrators on optometric scope of practice and other relevant issues.

Evaluating plans

Deciding whether or not to join a particular plan can be a difficult and time-consuming task. The AOA website’s Third Party Center page offers tools and advice to help optometrists assess:

  • Adequacy of a plan’s reimbursement
  • Potential increases in patient volume
  • Potential increases in practice gross income given the plan reimbursement levels and projected patient volume increases, and
  • Potential effects on practice net income considering practice expenses.

In addition to in-depth information on assessing fee schedules, the center offers advice on how to assess practical matters such as the burden a plan’s paperwork might place on office staff.

For practitioners who determine participation in a plan may be appropriate and represents a wise business decision, the AOA Third Party Center Web page offers information on credentialing for health plan participation.

Chair cost

In many cases, the decision to join an insurance plan provider panel will rest primarily on whether the plan’s reimbursements are sufficient to cover practice expenses.

To determine this, the practitioner must figure the practice’s chair cost – the average cost of seeing a patient in the office.

To help AOA members determine this key practice statistic, the AOA Third Party Center offers an interactive, online Chair Cost Calculator (www.aoa.org/x9619).

Using the calculator, optometrists can quickly determine their total annual office expenses and then divide the expense total by the number of patients seen in the practice each year to arrive at the average cost per patient.

The chair cost can easily be compared with the office visit reimbursements offered by a plan.
National health care reform could mean optometrists will be called on to provide care under a wider range of health insurance programs than ever before.

The methodic evaluation of participation in insurance plans therefore promises to become an increasingly important aspect of practice management, Dr. Montaquila noted.

The AOA Third Party Center will continue to offer products and programs to help optometrists and evaluate these plans.

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