Optometry holds ground with Medicare payer in Pennsylvania

Issue: October 2001

ByCharles B. Brownlow, OD

By the time you read this, the single stimulus for the article will be old news, but the reason for the article is timeless. The stimulus was a July 31 announcement from the Center for Medicare and Medicaid Services (CMS, formerly the Health Care Financing Administration) that the Medicare carrier for Pennsylvania should discontinue its move to stop payments to optometrists for certain covered services. The carrier had earlier created a Local Medical Review Policy that would have become effective Aug. 1, 2001, essentially setting aside determinations of scope that had earlier been made by the Pennsylvania Board of Optometry.

Carrier’s errors corrected

The carrier’s errors were corrected as a direct result of the vigilance, preparation, persistence and expertise of volunteers and staff of the Pennsylvania and American Optometric Associations. The errors would not have been corrected had it not been for those key representatives and without the vigilance and financial and moral support of the associations’ members.

Just as importantly, the errors could not have been corrected without the longstanding relationships that optometric associations maintain with state and regional carriers and with CMS, constantly providing information relative to the practice of eye care in the United States.

In the Pennsylvania situation, the carrier had historically sought determinations of scope of practice from the board of optometry and had then made payment decisions based upon those determinations. The Pennsylvania Department of State had ruled that state licensing boards are not permitted to issue advisory opinions on scope of practice. The Medicare carrier then stepped into that void and essentially made rulings of scope of practice by its own rule, which would have severely limited the covered services reimbursable to Pennsylvania doctors of optometry.

POA, AOA resolve the issue

Individual optometrists in Pennsylvania were powerless to affect these rulings by the Pennsylvania Department of State or by Pennsylvania’s Medicare carrier. Many agreed that it didn’t seem right that a payer could determine a profession’s scope, but it took the Pennsylvania Optometric Association (POA) and the American Optometric Association (AOA) to resolve the issue on behalf of all optometrists in Pennsylvania.

Subsequent to a meeting between CMS and representatives of the POA and AOA, CMS instructed the Pennsylvania carrier that, “We do not believe it is appropriate for the carrier to insert its judgment on the scope of practice absent any definitive state rulings. Additionally, the fact that the State Board of Optometry has moved forward with proposed regulations indicates that guidance to the carrier will likely be forthcoming.” The Department of State had ruled earlier that the optometry board could render scope-of-practice determinations using regulations.

Tail wagging the dog

Some of you may remember an earlier article in Primary Care Optometry News regarding my feeling that professionals are often caught in “tail wagging the dog” scenarios when dealing with payers. No such scenario can be any more offensive to health care professions than the situation in Pennsylvania, where a carrier essentially declared a state board unable to determine scope and subsequently anointed itself as the scope-determining body.

Every optometrist, and for that matter all members of all health care professions, must appreciate the actions taken by CMS, at the behest of the POA and AOA, in this case. Had these organizations not been vigilant or had they not been effective in their presentations to CMS, the carrier’s rulings might have stood, and a dangerous precedent might have been permitted to stand.

Instead, CMS has reaffirmed its longstanding policy of leaving determination of scope of practice to appropriate state agencies. This reaffirmation will be helpful to other state’s optometrists and to other professions who will face similar challenges by other payers in the future.

What can you do to be sure that future challenges are handled as well as this one? What can you do be sure that your profession is actively and effectively defended against discriminatory policies by insurers? Here are several suggestions:

Be connected. Loners will not survive in this millennium’s health care system. You need to have advocates. You need to have experts. You need to have spokespeople. You need to have resources. You need your state association and the AOA. Staff and volunteers will do much of the work for you on these challenges, but they cannot do it without the power that comes with representing a high percentage of the profession, and they cannot do it without the financial support provided by membership dues.
Be informed. You must do all you can to keep yourself and your staff well informed regarding current scope-of-practice issues in your state as well as the conditions contained in each of your third-party contracts. Without such knowledge, you will be at the mercy of each carrier’s interpretation of your contract and your scope of practice.
Be vigilant. It is critical that you know what each carrier is doing with respect to coding and payment issues and that all covered services within your scope of practice are being reimbursed by each carrier. Yes, you may be the first to discover that a service is not being reimbursed according to state law and according to the carrier’s contract with you. Every provider must watch for such errors or oversights.
Be vocal. Be sure that you let others know when carrier policy seems to be inaccurately interpreting your scope of practice with respect to covered services. If you believe a carrier is limiting your scope of practice, tell it so. Tell your state optometric association about it, too. State associations and the AOA cannot help you unless you let them know what kind of help you need.