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Optometric Bill of Rights

April 10, 2009

As I drafted the last President’s Column presenting a Declaration of Optometric Independence, I was about to share the message to nearly 300 industry executives at the Vision Monday Global Leadership Summit prior to Vision Expo East.
 
It seems fitting today as I depart Washington, D.C., after having met with several members of Congress and senators that I share my version of the Optometric Bill of Rights.    

The first five, in this issue, concern the rights of practitioners. With the national discussions of health care reform, it’s critical that optometry is clear with where we believe the profession must be, so we begin with the first five rights of optometrists.

First Amendment – Equitable Reimbursement – optometrists and ophthalmologists shall receive equal reimbursement for the same services regardless of the payer. There is currently discrimination in managed Medicare, some Medicaid and obviously in ERISA plans and even (possibly without common knowledge) traditional commercial insurers. Optometry, through the AOA and state associations, will need dues dollars and support in fighting for equal reimbursement for equal services.

Second Amendment – Truth and Transparency – optometrists shall be provided with easy-to-understand full disclosure statements by managed vision or health plans to more easily determine if joining a panel makes financial and  professional sense for his/her practice.  In particular, as in some managed vision plan carve outs of medical eye care – when there is disparity between reimbursement or scope of services provided between optometry and ophthalmology – the plan will clearly disclose the disparity and the optometrist can then determine if the lower reimbursement or limited scope of services provided is in the patients’, his/her practices’ or the professions’ best interest to join the panel.

Third Amendment – Optometric Co-Management and Intra-Professional Referrals – optometrists in all practice settings shall work closely with their optometric colleagues to ensure all patient needs are met by optometry whenever appropriate. This is a natural evolution for our profession and very successful in limited areas of the country for some specialties. There are thousands of patients who can benefit from vision therapy, low vision, sports vision and specialty contact lens referrals. In addition, based on experience, equipment limitations or practice settings, some optometrists choose to refer glaucoma and other medical eye conditions. In the future, those optometrists will first look to their optometric colleagues. The patients will be promptly returned to their family optometrist for care not based on the referral.

Fourth Amendment – Fair and Reasonable Reimbursement for Services Provided – The AOA will provide its members with tools and information to ensure that no optometrist shall ever have to make patient-care decisions based on the economics of reimbursement. Eye examination reimbursement will cover all costs of providing the services and a reasonable profit. The provision of professional services or materials will all cover the costs of providing the products or services and a reasonable profit.

Fifth Amendment – Lifetime of Learning and Professional Growth – all optometrists shall continue to commit to a lifetime of learning to ensure the best patient care possible. In addition, the optometric profession will never stop striving to provide necessary care to patients in need and will set no limits on the expansion of scope when it is in the patient’s best interest.
 

Because our patients are the focus of all we do, the next issue will conclude with my view of patient rights from a presbyopic perspective of optometric care.

8 comments

  1. Pete,
    I have been reading your optometric bill of rights blog with great interest and happy to see that someone else sees similar problems with vision plans and medical plans as I do. Sometimes we get the feeling that nobody in the AOA cares to step on the toes of the vision plans because they are big contributors to the AOA. My biggest problem with vision plans is the paltry reimbursement we receive for a comprehensive dilated exam. It used to be that we could elect not to take a particular plan. Now, we are required to take many vision plans to participate on medical plans. One particular issue is that Aetna will reimburse us around $150 for a non-medical routine eye exam whereas the corresponding vision plan, Eyemed will reimburse us $40 for the same exam. The problem is we are held to the same standard in a court of law as an ophthalmologist who is getting the $150 reimbursement whereas Aetna does everything it can to block ODs from using this higher paying benefit some patients have as part of their plan. It makes it tougher and tougher every year to do a dilated comprhensive exam on these low paying vision plans but if we miss something, our careers will be jeopardized forever if a lawsuit should come about. Is there anything the AOA could do to sit down with these vision plans and discuss the future of exam reimbursement. This can’t go on this way forever. If the AOA can battle the government over medicare reimbursement, why can’t it battle vision plans for their reimbursements. I always get the same anti-trust comment when I mention this. Thank you for your time and I look forward to your response.

    Scott Sanders, O.D.


  2. Scott,
    Thank you for reading and clearly this was not a concept that I thought of over night – or even just my idea. I’ve been listening to members throughout my 10 years on the AOA board and it really has come to a head in recent years with vision plans “carving out” medical eye care at significant discounts compared to ophthalmology.
    If the vision plans required ophthalmology to be carved out at the same fees as optometry – then that would be a business decision we all must make. However, the rub for me and our profession (and the charge the AOA is pushing) is when ophthalmology is allowed to continue to bill the medical plans and we as optometrists have to bill through a vision plan at a significant discount compared to the ophthalmologists.

    That folks is DISCRIMINATION and fortunately that is something the AOA can and will fight in the future at all fronts both public and private insurers. We will encourage and challenge plans to be transparent. As an optometrist, you should know if the plan you are signing up for reimburses (or allows more flexibility in scope of practice) ophthalmology differently so you can make your decision to join or not with full information.
    Rest assured, this is not just my personal mission – I’ve just gotten it started and we have put together a new Third Party Center within AOA to continue this and other initiatives to reduce the discrimination that seems to be “OK” with the vision plans.
    We all need to understand the value (and risk as you suggest) of the services we provide and the costs to operate our practices and start making BUSINESS decisions on whether to join vision or health plans and stop making EMOTIONAL or FEAR-BASED decisions.
    Stay tuned…….
    Pete


  3. In California, we are being discriminated against by the federal government by Medi-Cal no longer allowing an optometrist to perform medically necessary examinations, however allowing an ophthalmologist to perform the same level of examination.

    I would like to file a class action lawsuit. Does anyone know how?

    Alan


  4. I’ll check with the AOA office in DC, but unfortunately, because Optometry is not recognized as a physician in Medicaid, like we are in Medicare, the states, not the federal government has the ability to discriminate against a profession. This is a state issue and one that the AOA is working to correct at the federal level by gaining physician status within the Medicaid system – but the COA will have to work on the state legislature to gain full and equal inclusion within California. I don’t think a class action lawsuit would do any good – it would be very costly and because the federal law allows it – I don’t think it would be successful.

    I’ll do more checking and EVERYONE needs to lobby their congressman and senator as well as state legislators for full inclusion.
    Pete


  5. All insurers are middleman trying to get a piece of our action. They remind me of the organized crime element portrayed in “The Godfather” who hit up all the store owners each week for a slice of their profits. I would much rather deal with a “one payer” who pays us Medicare rates for a medical exam and also pay for a non-medical “wellness” exam. This would wipe out all the predatory vision care plans and for that matter all of the private insurers. Think of how simple it would be to deal with one set of rules. We could then concentrate on eyecare and not be sidetracked with having to be a “Philadelphia Lawyer”!


  6. Pete,
    Thank you for your response. Is there anything the AOA could do to set up a meeting with all the vision plans and maybe work out a deal to let us balance bill for exams like dentistry is allowed to do with many dental plans. I realize times are tough for everyone, vision plans included. So, asking for higher reimbursements isn’t likely to occur. That is why I think balance billing would be a logistical approach to negotiating with vision plans. If ophthalmology can negotiate with the government to let them charge the patient extra for crystalens/restor, them why can’t organized optometry negotiate with vision plans as a group? I hear anti-trust all the time as an excuse, but how can it be anti trust for one group and not for another. While I am all for billing medical when I can, vision plans still are a major player in most OD offices. If we don’t try something, private practioners will slowly fade away. Thank you for your time, Pete.

    Scott Sanders, O.D.


  7. AOA has an agenda…..it is to mainstream the wellness exam including refraction into basic health care coverage. No more confusion for the patients and the doctors.

    This will take time and effort on all of our parts, but it can happen and some insurers are listening with an open mind.

    Stay Tuned….
    Pete


  8. Scott,
    Your comparison to the balance billing for premium IOL’s is an interesting thought. Unfortunately, most vision plans are now telling their providers that the purchasers of the plans are looking for plans that limit the out of pocket expenses of their employees.

    I will forward your thoughts to our legal team to see if there is any possible way to consider this and avoid anti-trust issues.

    Pete



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