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Experienced ODs offer tips for becoming health plan providers
“At Issue” asked a panel of experts: What must an optometrist do to get on a medical insurance panel?
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Gregory Kraupa, OD: You would think that obtaining “panel provider” status with a medical health insurance plan should be simple and straightforward. After all, we provide high-quality medical eye care, and medical health plans are responsible for making that eye care accessible to their plan enrollees. Unfortunately, it is sometimes not quite that easy. When an optometrist applies for panel provider status, it is common for them to receive a denial notice with the explanation: “Our provider needs are being met in your geographic area by our current provider panel.” The optometrist needs to understand that this is simply a starting point and not a permanently closed door.
We need to realize that health plans are businesses trying to make a profit, and provider panels are an expense for them. We also need to realize it is the responsibility of the health plan to make medical eye care accessible to their enrollees. This is often the key to reopening that closed door.
Do your homework. Research the demographics of the health plan in question. How many providers do they have on their panel in your geographic area? What is the size of the enrolled patient population in that same area? How many providers have evening hours, weekend hours or 24-hour emergency care? How many of them offer specialty care in pediatrics or low vision?
Gregory Kraupa
Use this information to make a solid case that the health plan has significant gaps in patient access to care, and that your practice can help fill those gaps. Your argument should demonstrate clearly that you can help the plan provide better care. Then deliver your case to a member of the health plan who has the authority to make decisions. Identifying that person is probably the most difficult part of this whole process. Talk with benefits coordinators of local businesses. Ask insurance brokers. Look to your own patient base for people who work at the health plan. Do not send your message to the person answering the phone at the help desk.
If you still find the door is closed, enroll the help of your patients. Health plans nearly always listen to the voices of their enrollees. Have your patients enrolled with the health plan write letters to the plan requesting you on the provider panel. You will be amazed at what even 10 letters will do to help your cause.
Most importantly, be persistent. If you do not give up, you will eventually get on the panel.
For more information:
Gregory Kraupa, OD, is a Primary Care Optometry News Editorial Board member and president of Optometric Eye Care Centers PA. He can be reached at 1202 Moore Lake Dr. East, Fridley, MN 55126; greg.kraupa@eyecarecenters.net.Scott A. Edmonds, OD, FAAO: Most health insurance panels will accept applications from optometrists. Optometrists interested in providing medical care should request an application and follow the guidelines provided. Most plans will require documentation that an optometrist is fully licensed to provide medical care to the maximum scope of practice in the state, and the provider’s malpractice coverage must be equal to other health care providers who provide the same level of care.
Scott A. Edmonds
There are several tips that, although not always required, will be helpful in a successful application. The first is the use of the Council for Affordable Quality Healthcare (CAQH) Universal Provider Datasource. CAQH provides a data warehouse for provider credentials. Many insurance panels use this resource to verify them.
Another recommendation is to have a Drug Enforcement Administration (DEA) number. Optometrists may apply for and be granted a DEA number for a modest fee. The number needs to be renewed periodically, and the fee is payable at each renewal. Some health plans and many pharmaceutical companies track a provider’s treatment plans with the use of this number.
A common question from optometrists is the requirement for board certification. I have yet to find a health plan that requires that an optometrist be board certified for admission to a medical panel. The current state of board certification is that there are too few optometrists who have attained this credential from the American Board of Optometry. The American Optometric Society is now defunct, and the more universal passage of the “boards” from the National Board of Optometric Examiners does not provide a certification. As such, most optometrists can just write “not applicable” on this space of the application and avoid the entire issue. Due to optometry being trained and licensed as a specific health care profession, board certification for optometrists is a different credential than the specialty board certification for broadly trained medical doctors.
For more information:
Scott A. Edmonds, OD, FAAO, is a Primary Care Optometry News Editorial Board member, chief medical officer of MARCH Vision Care and the co-director of the Low Vision/Contact Lens Service at Wills Eye Institute in Philadelphia. He can be reached at scottaed@aol.com.Allan Hudson, OD: It may be easier to gain access to a medical insurance panel in a rural area than in an urban area. We have been billing medical insurance in our offices since the 1980s and have found the process to be easier since Medicare began allowing optometrists to participate.
We have met with local carriers and have had no problem gaining access to medical panels, especially if we are already vision panel members for the same carrier. We have also been prepared to drop a vision panel membership if we were denied medical panel participation, which most carriers, I believe, are not ready to deal with.
Everything local is politics, and all politics are local. In our rural area, we (local optometric physicians) have met with local ophthalmologists on several occasions to unite when we have dealt with local carriers and carriers new to our region. This somewhat united front has given the local ODs and MDs both better access and negotiating strength.
Allan Hudson
In one example, a local carrier decided to give a vision benefit to a Medicare Part C plan. We (the ODs and MDs) negotiated a co-pay for the member to pay instead of the providers losing the refraction fee, since the exam reimbursement was based on a 92004/92014 reimbursement without the 92015 code.
Our relationship with our local primary care physicians has always been a source of medical and vision referrals. I believe that a personal relationship is necessary with the PCPs, and throughout my 30 years in practice I have tried to foster those relationships. The local PCPs have helped our office gain access to medical patients and have authorized referrals for managed care plans. With the Affordable Care Act and Coordinated Care Organizations just down the road, it is necessary to continue those relationships and to provide medical care in an affordable and efficient manner.
For more information:
Allan Hudson, OD, is in private practice at High Desert Vision Source, in Redmond, Ore. He can be reached at idoc1981@aol.com.Charles B. Brownlow, OD, FAAO: I will take a different slant on this question and answer it from a business angle. Before the doctor considers signing up with a new insurer or renewing a current contract, the doctor should have her/his accountant help analyze the financial and professional needs of the practice.
Some questions should be answered prior to accepting or renewing a contract.
Does the practice have capacity for additional patients?
Charles B.
Brownlow
What is the practice’s “break even” point relative to the cost of providing services and the reimbursements received?
Does the insurer respect the doctor’s full scope of services as permitted by state law?
Are the fees the insurer is offering based on the service provided or upon the license of the provider? (In other words, does the insurer reimburse optometrists at different fees than MDs?)
How do the conditions and reimbursements of each contract compare to other contracts the practice has accepted?
Will the insurer permit the practice to negotiate for better conditions and/or reimbursements that match the needs of the practice?
Is the practice willing to negotiate for better conditions and/or reimbursements on behalf of its patients and on behalf of the fiscal well-being of the practice?
Health care providers have to realize that they are businesses and that their business cannot continue unless they produce net income from the services they provide. Your accountant may well find that one or more of your insurance contracts reimburses you at rates that result in negative net. In other words, it may be costing you money to have the patient in the chair. You would be better off going fishing or sitting in the back room reading a book. Obviously, you should not be renewing or signing a contract that costs you money.