Central Ohio Optometric Association

Newsletter from OOA Third Party Committee 

1st Quarter 2011 This quarterly Newsletter from the OOA Third Party 
Committee includes third party topics of interest to OOA members. Let us 
know if there is a topic you think should be included. William Rudy, OD, 
Chair; Nathan Bjork, OD; Heath Gilbert, OD; Larry Gill, OD; Steve Hansen, OD; 
Jay Henry, OD; Michael Ringel, OD; Dave Shilling, OD; Steve Shroder, OD; 
Eric Stocker, OD; Brent Swartz, OD; Richard Cornett.  
 
While the OOA represents ALL optometrists in the State of Ohio, the Third 
Party Committee deals with issues that affect Ohio optometrists and their 
relationship with third party payors. The OOA cannot and will not recommend
policy on how individual optometrists sign up for various third party 
contracts.  Each OD should consider their unique situation, the third party
contract, and their mode of practice individually before deciding to enroll
in a plan.  If a third party payor is acting outside of the contract 
parameters or outside state or federal law, send an email to the OOA with 
details so the Third Party Committee can investigate.  In the past, the 
Third Party Committee has tried to deal with problems that OOA members have
with insurance payors after a member experiences a problem.  In other words,
the Third Party Committee has been retroactive and "put out fires" after 
they arose.  This year the committee is trying to distribute information to 
OOA members to educate and to inform.  We, the Third Party Committee, want 
these emails to inform Ohio optometrists regarding third party issues. Here
are a few current topics:  
VSP and Costco:  
http://www.visionmonday.com/ViewContent/tabid/211/content_id/26393/Default.aspx 
http://www.revoptom.com/content/c/24986/ 
VSP started a pilot program that allows Costco to sell contact lenses and 
some optical goods directly to VSP members without the hassle of patient 
reimbursement.  Ohio optometrists  report to the OOA that their patients 
have used VSP benefits to purchase CLs through Costco.  According to a VSP 
rep, some large potential employee groups are refusing to allow VSP to bid 
for vision contracts without a national retail component. Costco was chosen 
because they were already VSP's largest out-of-network provider. Costco was
only given the privilege to verify patient eligibility electronically and 
file claims electronically. They are still out of network and reimbursed as
an out of network provider.  However, VSP doctors have complained that 
Costco is selling the CLs directly to the consumer at the same price as 
in-network providers.    This pilot program has met with significant VSP 
provider controversy since historically, VSP has aligned themselves with 
private practice, not "retail" or "commercial" settings.  In the past, in 
order to be a VSP provider, the optometrist had to own a majority of the 
optical supply and was required to carry certain frames.  Aligning with 
Costco, a large corporation that has independent doctors of optometry and 
who have no financial tie to optical sales, is a departure from previous 
VSP policy.    VSP reps again stress that this is a pilot plan that is based
on economic environment or market forces.  To be competitive with today's 
changing health care network, VSP must alter its policy in order to keep up
with demand.  The thought is that network providers will benefit with more 
clients in the VSP network instead of networks that cater solely to large 
optical chains.  VSP has 55 million VSP vision care members in its network 
in 2011 which is up from 40 million in 2008. 
 
VSP and eyeconic.com: 
http://www.sightnation.com/news/vsp-global-test-online-optical-store-eyeconiccom 
VSP has also launched an online optical component to compete with the trend
of online optical sales.  The eyeconic website recognizes that VSP providers
may have concerns with promoting the new mode of optical sales: "We've heard
and understand the concern doctors have regarding online sales, especially 
the fear of reducing patient visits..."  The VSP statement goes on to state
that eyeconic.com will be "the right online partner for independent eyecare
providers" by offering "a virtual extension of their dispensary." 
Eyeconic.com and VSP's online optical sales went live February 18, 2011.  
 
Medicare/Medicaid and Refractions: http://codes.ohio.gov/oac/5101:3-6 
Ohio optometrists are reporting that most Ohio Medicaid and Medicaid HMOs 
are not paying for Refraction 92015 separately than eye codes comprehensive
920x4 or intermediate 920x2 codes.  Some optometrists were reporting that 
Molina (OH Medicaid HMO) WAS paying for refractions regardless of other 
92xxx codes, but a recent report stated they had recently changed this 
policy as directed by Ohio Medicaid.  Most Medicaid branches consider that 
92015 is bundled into eye codes 920x4/920x2.  Ohio Medicaid and some 
Medicaid HMOs are paying for 92015 when billed in conjunction with E/M 
medical codes 99xxx.  However, a medical diagnosis and treatment is needed 
to justify a 99xxx code to be billed.  Also, eyecare providers should be 
aware that some Ohio Medicaid third party payors will only pay for ONE 
92xxx code in a 2- year period and this includes Refraction 92015.  
Therefore, if a provider does bill a 92015 in conjunction with a 99213 
(E/M level 3 established) then that patient's Medicaid vision benefits have
been used and Medicaid will deny any 92014 or 92012 CPT codes for a certain
period.  Medicare has historically considered 92015 refractions an allowable, 
non-covered item.  Doctors can bill patients directly for this service since
it is not "bundled" in an eye exam code or E/M code.  Historically, the 
refraction fee has been approximately 20% of a doctor's comprehensive 920x4
code, but there seem to be no written recommendations, only historical 
data.  Interestingly, Medicare REQUIRES that a refraction (to establish a 
best corrected vision (BCVA)) be performed within 3 months of cataract 
surgery, but Medicare does not cover the fee.    When Medicaid is a 
secondary insurance of Medicare, Medicaid still follows their interpretation
that 92015 is bundled into 920x4 or 920x2 even though the primary Medicare 
states that it is not bundled into those CPTs. Questions have arisen in the
current (2012-13) state budget regarding Medicaid as “secondary.” The OOA 
has asked for clarification on this matter. 
Medicare Switch from Palmetto 
to Cigna: website: http://www.cignagovernmentservices.com/J15/  
Ohio Medicare will be switching from Palmetto to Cigna.  The OOA is hard at
work trying to build new ties with Cigna.  Unfortunately, many large 
insurance companies do not understand today's optometry.  Also, the Medicare
guidelines can be interpreted in different ways so we expect some early 
misunderstanding and unfortunately denials in the coming months.  Please 
know that the OOA is trying to be proactive and establish a good working 
relationship with Cigna.  
UAW 
Dr. Peter Agnone, Michigan optometrist, reports that United Auto Workers 
retired workers and their dependents will now have access to their 
optometrists for medical eye care beginning April, 1, 2011.  
Blue Cross/ Blue Shield of Michigan is the administrator for the UAW 
Retiree Medical Benefits Trust. The “Trust” provides health care benefits 
for retired UAW members of General Motors, Ford and Chrysler, along with 
their eligible dependents.  Currently, the Trust provides health care 
benefits to more than 860,000 persons. This is good news for the UAW 
workers.  This change of policy by the UAW Trust decision makers will be 
significant and helpful as I continue my discussions with the auto 
companies for access to optometrists for all autoworkers.  Please feel free
to disperse this information to our members as you see fit.  BC/BS will 
announce this change in their April “The Record” bulletin that goes out to 
all providers.