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Optometry makes headway against insurer mandates
Bills benefiting ODs have been passed in Maryland and Texas.
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Laws prohibiting forced discounts by insurers on optometrist services have passed in Maryland and Texas, and hopes are high for a scope of practice expansion in California next year.
Texas
Texas optometrists can now compete in their local marketplace on noncovered services and products without the one-size-fits-all discounting approach mandated in most managed care contracts, a Texas Optometric Association (TOA) representative said in an interview with Primary Care Optometry News.
SB 632 prevents managed care plans from capping fees and requiring discounts on services and products provided by optometrists not covered in the benefit plan, Thomas A. Lucas Jr., OD, TOA legislative chair, said in the interview. He clarified that a covered product or service is one with an available reimbursement amount to the doctor.
“Before, if an optometrist wanted to provide covered services to a patient, they also had to agree to often-times onerous terms on noncovered services,” Lucas said. “These policies have harmed optometry offices and those patients who are not covered by the policy because the optometry office typically had to make unnatural business decisions to accommodate a take-it-or-leave-it contract.”
According to Lucas, the bill received heavy opposition by trade groups of vision plans and health plans as well as optical chain retailers, he said.
“Ultimately, common sense prevailed,” Lucas said. “The bill was successful because legislators understood how the enticement overreach of the benefit plans was a downward spiral, hurting small business doctors, and that big business had an unfair advantage over small business in terms of negotiating strength. It is the optometrist, not the insurance company, who ultimately keeps society seeing clearly through healthy eyes. If our optometrists are being harmed by and made to pursue bad competitive business strategies, what good does that ultimately do for the patient who relies on our care?”
Moving forward, the TOA is working with some of the major vision plans to help restructure contracts and benefit plans and will continue to work with managed care companies to ensure they understand their participating doctors’ concerns with policies and programs, he said.
Maryland
Similarly, HB 1160 in Maryland will prevent insurers from including any provision within a vision provider’s contract that forces the provider to discount services and materials not covered by the insurance plan, according to a Maryland Optometric Association (MOA) representative.
“Unlike any other provider, prior to this legislation, ODs were at the mercy of the insurer with regard to what fee they were permitted to charge patients for such things as a routine eye exam or a first or second pair of glasses,” Jennifer Levy, executive director for the MOA, said in an interview with PCON.
Even though the patient’s insurance plan did not cover these services or materials, the insurer was still permitted to mandate that the doctor provide a discount to the patient, an arbitrary number decided upon and able to be changed by the insurer at any time, according to Levy.
This meant the provider was forced to charge a significantly lower rate for services or materials the patient’s plan would not cover and for which the provider would receive no additional reimbursement, she said.
“HB 1160 also addressed another insurance provision that we’ve been seeing more and more of, where the insurer would force an OD to participate with their discount vision plan in order to be paneled on the same insurer’s major medical network,” Levy said. “This is especially problematic for Maryland optometric practices with a business model focused primarily on medical eye care.
“Depending on a practice’s business model, these provisions prevented them from taking certain insurance plans and seeing certain patients,” she said. “The new law should improve access to primary eye care for optometric patients throughout Maryland.”
California
A bill aiming to expand California optometrists’ scope of practice has been tabled by its creator, Sen. Ed Hernandez, until early 2014, according to the California Optometric Association (COA) president.
“Virtually all scope bills end up being 2-year bills,” COA President Fred Dubick, OD, MBA, FAAO, said in an interview with PCON. “There were some positive changes during the legislative progression, and we were very pleased with them, but we wanted to take a little bit more time to make everybody comfortable with the bill. It’s been a mostly cooperative process, and we’re pleased that the new chair of the committee where it’s going next has called for a work group and is making our bill a priority.
“We’re already in discussions with our team to get that work group going,” Dubick said. “We’re going to work on it over the next few months with the other side and hopefully bring back something everyone can be comfortable with and support come the beginning of the session in January.”
The bill, SB 492, is sponsored by the COA and has already passed through the senate side of the California legislature, he said.
Among other things, the bill would allow optometrists to prescribe U.S. Food and Drug Administration-approved drugs for treating the eyes and deliver the drugs in whatever manner the drug is approved to be delivered, including injection. However, this does not include intra-orbital injections or botulinum toxin injections, according to Dubick.
The bill would also allow optometrists to administer immunizations, he added.
“With the Affordable Care Act coming into play in January 2014, we projected that millions of people will be added to the system in California, and there aren’t enough primary care docs to take care of them,” Dubick said. “SB 492 is an effort to bridge that gap in primary care.” – by Daniel R. Morgan