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The primary care doctor must be a patient advocate
Now that the implementation phase of the Affordable Care Act is upon us, optometrists are seeing more patients with new health insurance. The coverage for medical eye care is fairly straightforward, but coverage for the new routine eye exam and glasses benefit is not so clear.
In speaking with some of my colleagues who have more of a “routine exam” practice, I find that there is confusion on the part of the covered member as well as the carrier of the vision benefit. Most health plans that participle in the health care exchange have carved out the routine eye exam and hardware benefit to one of the existing vision plans around the country. Theses plan have had to develop new products to meet the benefit design that was required by each state that provides these services.
Unfortunately, optometry is poorly represented in state health care agencies where the vision benefits were designed. As such, many of the plans are poorly designed and illogical based on the way eye care is provided. The plans have hidden traps such as high deductibles or high copays or both, such that the member has very little actual coverage at the optometrist’s office. The member, however, is expecting full coverage for the exam and a wide selection of glasses. This disconnect can result in a high level of frustration for both the doctor and the member.
For regular readers of this blog, I have discussed that the promise of the Obama Administration has always been “change.” We are only just beginning to see real evidence of this change. The good news is that new patients are in your office for a primary care-based eye examination. Over the long run, this will lead to better vision for learning and working as well as better health outcomes for chronic medical problems. The bad news is that patients and doctors and, frankly, health care administrators do not know how to get the payment side of the new system to work.
Part of the responsibility of primary care is to learn as much as possible about the new system and how the carriers in your area are administering it. Then you must spend some time working with your patients to explain the program and educate them before the services are provided so they understand any financial implication before the services are rendered.
I make this sound easy, but it is not. Doctors or their billing staff will need to spend some time on the phone with the carriers. The carriers will not have the answers and will not understand their own program. Be understanding and polite, but get to the bottom of all of your issues. Cooperative providers are often the source of improvements in health care administration. Your feedback matters.
The next problem is explaining to the member that their benefit may not cover what they expect. Again, be understanding and realize that your new patient has probably also been misinformed. Explain to them that if they are not happy, they must also respectfully complain to their health plan that they have been misled or that their benefit is not logical for their needs. Their feedback matters.
Think of these new benefits the same way as a new piece of software. We have all been excited to get version 1.0 of a brand-new application only to find that there are many “bugs” that can only be fixed by working with the program and then providing user feedback. We are the end users of Affordable Care 1.0. We must work through the bugs and provide the feedback so that we can quickly get to the release of ACA 2.0.