Newest TPA states clear most hurdles of third-party payers, pharmacies, MDs

Issue: November 1999

Optometrists in three states that recently passed therapeutic pharmaceutical agent (TPA) laws have implemented prescribing in their practices and found that the challenge of achieving full scope of practice did not end in the legislature. Following passage of the law, practitioners learned to contend with insurance companies and pharmacies that often did not recognize their new privileges, as well as the limitations that come with not having a Drug Enforcement Administration (DEA) number. Over time, optometrists and their state associations have met these challenges and have begun looking ahead to expanding their prescribing privileges.

In California, Massachusetts and Pennsylvania almost 10,000 optometric licenses have been issued, about one-fifth of the total number of licenses in the United States, according to the International Association of Boards of Optometry. Practitioners in each of these states related to Primary Care Optometry News some of their trials following TPA certification.

Third-party payer problems in California

After the prescribing bill was passed in California, doctors initially had varying degrees of success in obtaining reimbursement for medical services from insurance companies. Philip Smith, OD, in private practice in San Diego, told Primary Care Optometry News that billing insurance companies for his services was relatively easy.

“For some reason, insurance companies just seemed to be more educated about what we can do when they pull up our billings. I’m getting 80% to 100% reimbursement for what I bill out. If I treat a blepharitis or do a foreign-body removal — something within our scope — I get a pretty good reimbursement,” Dr. Smith said.

For Robert Gordon, OD, in Encino, Calif., it took a considerable amount of letter writing and communication to educate insurance companies about the expanded scope of practice. “Most of the letter writing has been to explain that the patient came in for a medical procedure, not for a vision care need, and the patient should be reimbursed under their medical care policy. When insurance companies saw ‘optometrist,’ they just perceived vision care and not eye care services,” Dr. Gordon said.

These questions about scope of practice have since been resolved, through his own efforts as well as those of the California Optometric Association, he said. “It is very rare now that we have to explain that optometrists are allowed to bill for services,” Dr. Gordon said.

On the other hand, HMOs have not proven as easy to penetrate. Large multidisciplinary medical groups that allow a payer to have all disciplines covered under one contract are more attractive to the payers because they allow greater cost control, said Kenneth N. Schwaderer, OD, in Mountain View, Calif.

“Cracking into HMOs is a problem for independent optometry practices because you’re not a member of those groups, either business-wise or association-wise. It’s difficult to get in there, unless you want to sell your practice and be absorbed into the medical conglomerate. Optometric societies have not gotten organized to the point where they can go out and bid for these eye care contracts on a local level,” Dr. Schwaderer said.

This is a problem for doctors in other specialties as well, and from the HMOs’ perspective, it is more efficient to contract with one group for a wide range of services rather than dealing with a number of individual specialty groups, he said.

“Optometry is just going to have to look for a way to infiltrate that with good business principles, because that is the bottom line for the HMOs — they have to be in the black,” Dr. Schwaderer said.

Also standing in the way are the differences in scope of practice from state to state. “It’s very difficult to make an agreement with an insurance company that crosses state borders and to carve out a certain block of care when it varies so much from one state to another,” Dr. Schwaderer said.

Prescription reimbursement

Having prescriptions filled was not a significant stumbling block, but because optometrists in California cannot prescribe controlled substances and, thus, do not have DEA numbers, pharmacists had difficulties obtaining reimbursement for optometric scripts.

“Insurance companies required pharmacists to use a DEA number to bill for drugs they dispense,” Dr. Gordon said. “The state association went back to the legislature and had a law passed that prohibited insurance companies from using DEA numbers to bill for insurance.”

An agreement was eventually reached where pharmacists would use optometrists’ TPA license numbers and add zeroes to complete the space on the form. A TPA amplification bill to be introduced next year proposes adding limited controlled substances and allowing ODs to apply for DEA numbers.

Improved ties with ophthalmology

In 1996, when California ODs were pursuing prescribing privileges, other events coincided to smooth expanded scope of practice issues with ophthalmologists, Dr. Gordon said.

“The excimer laser was about to be approved, and everybody was wondering where they were going to get patients for refractive surgery,” he said. “At the same time, cataract and glaucoma comanagement were coming into vogue. I think all these things came together and actually improved relationships. I think it removed the strains from the battle we would have had to get therapeutic privileges.”

The ability to treat patients who were previously referred also has improved communication with the medical community at large, Dr. Schwaderer said.

“It has helped our practice feel like more of the medical team,” he said.

Reimbursement comes slowly to Mass.

Massachusetts ODs are still gradually finding acceptance with HMOs and insurance companies in their state. The Massachusetts Society of Optometrists has communicated its members’ privileges to the third-party payers, but there are still some holdouts, said Neil Casey, OD, in practice in West Boylston, Mass. “The society has been able to conduct negotiations to get us recognized for our full scope and gradually, one-by-one, open the doors and increase reimbursement for the new levels of service we can provide,” Dr. Casey said.

The initial resistance by managed care entities was frustrating for doctors and patients alike. “You could see patients but could only get reimbursed 20% of the time for the TPA services you were providing,” Dr. Casey said. “It was limiting initially in that you were able to treat patients on some plans and not those on others.”

Even though it was an out-of-pocket expense, many patients elected to seek his care. “The insurance coverage might not have been there, but there was a willingness of the patients to be treated in our office,” he said.

The inconvenience for patients works to the optometrists’ advantage in dealing with insurance companies, said Ron Ferrucci, OD, in Milford, Mass. “The delay is somewhat of a frustration, because patients are expecting us to provide this service,” he said. “They will be the ones to drive insurance companies to act a little faster, because we are their providers of choice. If they were on another plan that allowed us to take care of them and then they switched and we were no longer able to, they would get upset. They can be our best advocates when we are faced with a situation like that.”

DEA concerns loom in future

Communication with pharmacies in the state has been smooth, and pseudo-DEA numbers were issued to allow pharmacies to track prescriptions and be reimbursed, eliminating two potential problems. The lack of a DEA number still poses a concern for ODs, Dr. Casey said.

“The DEA issue is the threat of a wrinkle — it’s a possibility that some insurance plans may require a DEA number to become a participant in the plan,” he said. “Is it going to be a way that we could be bumped off panels come recredentialing time?” he said.

HMO law eases reimbursement in Pa.

In Pennsylvania, HMOs are required by state law to reimburse optometrists for services within their scope of practice if a physician performing that same service would have been reimbursed. This has given ODs leverage in their relationships with HMOs, said Charles Stuckey, OD, executive director of the Pennsylvania Optometric Association.

“In some cases, we might not have that leverage with some types of payers, but in Pennsylvania, we’re in good shape with the HMOs,” he said.

For the most part, transitioning from vision care to full medical service providers has been smooth. Dr. Stuckey has worked with the medical directors of HMOs and insurance carriers to ensure that the new scope of practice is reflected in operational changes so ODs will be properly reimbursed.

The expanded privileges also eliminated an obstacle for seeking referrals from primary care physicians, said Scott A. Edmonds, OD, who has pediatric and low vision clinics at Wills Eye Hospital in Philadelphia and at Lankenau Hospital in Wynnewood, Pa., and has a primary care practice in Great Valley, Pa.

“Prior to this, it was very awkward to ask for a referral, then find out you needed to use a medication and have to refer the patient on, or return the patient back to the primary care physician,” Dr. Edmonds said.

Practitioners should understand that their inclusion in the vision care side of a plan does not necessarily affect their ability to offer medical care, Dr. Edmonds said. He is a medical provider for Keystone Health Plan, an HMO covering eastern Pennsylvania, and is able to receive referrals from primary care physicians associated with Keystone. However, he does not provide vision care for Davis Vision, the vision program for Keystone.

Communication with pharmacies

When the list of drugs optometrists could prescribe was approved in the state of Pennsylvania, the state board of optometry forwarded this list and the credentialing requirements ODs needed to the state board of pharmacy, which in turn disseminated it through the Pennsylvania Pharmaceutical Association. As a result, there was little question about ODs prescribing, Dr. Stuckey said.

When the TPA list was approved, it included controlled substances, but ODs had to wait to apply for DEA licenses until February 1999. In the meantime, ODs in the state had problems similar to those faced in California with pharmacists requiring a DEA number before they would bill insurance companies. When the DEA began issuing licenses to ODs here, this ceased to be a problem.

Endorsement from other medical providers

Expanding privileges can only strengthen relationships with ophthalmology and other medical providers, Dr. Stuckey said. “It has decreased costs for the patient, and it has improved the quality of care optometrists can provide. If you do something better for the patient, I think you improve your relationship with ophthalmology,” he said.

Because most of Dr. Edmonds’ work is in low vision and specialty services, which were unaffected by the expansion of prescribing, he has not seen a significant change in his practice. With patients who were being comanaged for glaucoma, Dr. Edmonds has treated other conditions that have arisen without complaints from ophthalmologists about treating their patients with medications.

In one case, Dr. Edmonds sent a patient who had advanced herpes and did not respond to topical antivirals for a consultation with a corneal specialist. “He saw the patient, agreed we had made the right diagnosis and suggested we put the patient on orals,” Dr. Edmonds said. “It was a positive endorsement that we have the privileges to treat, because the ophthalmologist said, ‘Orals are in your scope now, so you go ahead and write it.’ ”

For Your Information:

Philip Smith, OD, can be contacted at 3666 Fourth Ave., San Diego, CA 92103; (619) 297-4331; fax: (619) 297-6572.

Robert Gordon, OD, can be contacted at 16255 Ventura Blvd., Suite 705, Encino, CA 91436; (818) 986-8860; fax: (818) 986-7324.

Kenneth N. Schwaderer, OD, can be contacted at 495 Castro St., Mountain View, CA 94042; (650) 967-6649; fax: (650) 967-0237.

Neil Casey, OD, can be contacted at 67 West Boylston St., West Boylston, MA 01583; (508) 845-6414; fax: (508) 835-3244.

Ron Ferrucci, OD, can be reached at 192 West St., Milford, MA 01757; (508) 473-0395; fax: (508) 478-3392.

Charles Stuckey, OD, executive director of the Pennsylvania Optometric Association, can be contacted at PO Box 3312, Harrisburg, PA 17105; (717) 233-6455; fax: (717) 233-6833.

Scott A. Edmonds, OD, is a member of the Primary Care Optometry News Editorial Board and can be contacted at 53 Medical Office Building East, Lankenau Hospital Complex, Wynnewood, PA 19096; (610) 644-0391; fax: (610) 325-9241; e-mail: scottaed@aol.com.