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Insurance companies now allow Georgia providers to deliver ‘direct eye care’
The insurers can no longer impose an optical lab requirement, according to a practitioner who sued Spectera.
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After a November 2013 ruling that declared insurance company Spectera’s agreement with optometrists in violation of Georgia law, other insurance companies have changed their polices, according to an optometrist who practices in the state.
Steven M. Wilson, OD, detailed the situation in an interview with Primary Care Optometry News.
“The direct result of this lawsuit is that Spectera was required to change all the contracts in the state of Georgia such that the provider can choose to provide eye care, that is, the preparation and supply of eyeglasses and contact lenses, from the provider’s own inventory and optical lab directly to the patient,” he said. “Also, Spectera cannot impose an optical lab requirement that precludes the enrollee from receiving that eye care directly from their eye care provider,” he said.
“Afterward, VSP, Davis Vision, EyeMed, Avesis and VBA all acknowledged that the act and the opinion are applicable to them,” Wilson continued. “They changed their contracts or online manuals or some combination thereof to allow the eye care practitioner to provide eye care directly to the patient and choose appropriate eyeglasses and contact lenses without being required to use the vision insurance’s optical lab.”
Spectera contracts changed in 2010
According to the Supreme Court decision for Spectera Inc. vs. Wilson, in 2010, Spectera terminated its Patriot contracts that had been in place. These contracts had allowed providers to use their own materials, and Spectera would reimburse them for those materials.
The insurance company replaced the Patriot contracts with independent participating provider agreements that specified that the provider must agree to use Spectera’s optical laboratory for services or products for enrollees.
According to an affidavit from Lori Archer, senior vice president of provider network solutions for Spectera, providers “would be required to obtain covered materials from Spectera when servicing Spectera insureds,” and the only materials providers could provide “would be noncovered materials such as prescription sunglasses or spare pairs of eye glasses.”
Additionally, Spectera admitted in its court filings that under the IPP agreement “[appellees] would no longer receive the reimbursement for materials from Spectera and would no longer be entitled to retain the materials copays from Spectera insureds.”
Wilson files suit
Wilson, along with Cynthia McMurray, OD; Jodie E. Summers, OD; and David Price, OD, who were all employed at Wilson Eye Center, sued the insurance company on the basis that the new agreement violated Georgia’s Patient Access to Eye Care Act.
“A health care insurer providing a health benefit plan [that] includes eye care benefits shall not preclude a covered person who seeks eye care from obtaining such service directly from a provider on the health benefit plan provider panel who is licensed to provide eye care,” the act reads.
“[The term] ‘eye care’ shall mean those health care services and materials related to the care of the eye and related structures and vision care services [that] a health care insurer is obligated to pay for or provide to covered persons under the health benefit plan,” it continues.
Wilson explained to PCON: “We litigated the act specifically under subsection (c)(2) because Spectera was requiring the provider to provide that eye care – that is, the preparation and supply of eye glasses and contact lenses – from Spectera’s optical lab rather than from the provider’s own lab. We felt that was a violation of (c)(2). There were more aspects of the case, but that was the primary part we were litigating under.”
After proceeding through the trial court and an appeals court, the case made it to Georgia’s Supreme Court.
The justices stated in their decision:
“Specifically, the agreement prohibits appellees from assembling lenses and frames to provide a complete pair of eyeglasses to Spectera insureds and it prohibits appellees from supplying Spectera insureds with contact lenses they have in their inventory at Wilson Eye Center.
“Inasmuch as appellees cannot provide certain eye care – in particular the preparation of eyeglasses – directly to Spectera insureds, the IPP agreement violates the subsection (c)(2) of the act, and the judgment of the Court of Appeals must be sustained,” they continued.
Other states
Wilson noted that Georgia is alone in this type of ruling.
“Some states have different types of rulings about precluding things like discounts, but in the other 49 states, the requirements from Spectera, VSP, Davis Vision, Avesis and EyeMed that the provider be precluded from providing that eye care (preparation and supply of eye glasses and contact lenses directly to the patient) are still in effect.”
He also disclosed to PCON that, for the litigating optometrists, it was an issue of service and not of financial gain.
“To take away that service from the enrollee and the provider has a direct impact on the patient,” he said.
Effect on patients
Wilson highlighted several examples in which the agreement Spectera tried to enforce would have negatively affected patients.
“Let’s say a patient wants to use their old frames and they only have one pair of glasses, and the contract precludes me from providing lens edging and finishing in my own optical lab. Then I’ve got to take that one pair of glasses from the patient and ship it to Baltimore, and it’s going to be 2 weeks until the patient gets their glasses back. What’s the patient to do for 2 weeks?
“Or, let’s say a patient comes in on Friday afternoon at 3 o’clock, they’ve broken their glasses or they’re going on vacation and they’ve used their last contact lenses,” he continued. “They would have to wait for the insurance company optical lab to provide the glasses or contacts in a week or two or three, whereas we can provide it in an hour or two in our office. It’s just a service issue; it’s always been a service issue.”
Spectera did not return an invitation to comment for this article. – by Chelsea Frajerman