News from the AOA's Blog

The new AOA Third Party Center (TPC) has initiated a five-year plan to expand insurance coverage for eye care services and ensure appropriate reimbursement for the optometrists who provide them.

Approved during this year’s AOA Spring Planning Conference, the center’s new strategic plan will focus on four main activities, according to Mark J. Hennen, O.D., chair of the center’s executive committee:

• Establishing eye examinations as a standard benefit in medical plans.
• Seeking inclusion of optometrists as providers under all Employee Retirement Income Security Act (ERISA), medical and vision plans (with the same levels of reimbursement as ophthalmologists).
• Monitoring health care trends (especially those related to the national health care reform initiative), and
• Assisting practicing optometrists in developing good relations with local insurance carriers as well as providing optometric practices guidance on the rules, regulations, and coding systems they must understand to properly file claims.

Understanding the value of integrating eye care into the medical plans is critical for improving the health of all Americans, according to AOA Executive Director Barry J. Barresi, O.D., Ph.D.

Coverage for eye examinations under separate vision plans is not a comprehensive approach and introduces unnecessary barriers to preventive and medical eye care, he contends.

Dr. Barresi emphasized that message heavily in addresses to the AOA House of Delegates at Optometry’s Meeting®, Vision Expo and the National Association of Vision Care Plans this year.

Employer-based health programs often “partner” with vision plans to offer coverage for eye examinations and related services as an option for employees, according to Pauline Yan, vice president of Integrated Healthcare Market Solutions at Essilor of America and an adviser to the AOA Third Party Center.

However, “mainstreaming” eye examination coverage into the primary benefit plan holds a number of benefits for insurers, employers and beneficiaries, Yan contends.

Insurers who offer comprehensive eye examination coverage are not only more competitive in the marketplace but have access to eye examination data that can be critical in measuring outcomes and managing chronic disease, such as systemic diabetes and hypertension, Yan notes.

Employers have increasingly come to understand the value of eye care to their employees, she adds (see AOA News, January 2009.)

The center will also support a number of other important AOA goals and objectives, according to Dr. Hennen.

It will expand programs developed by the AOA’s previous insurance relations entity, the Eye Care Benefits Committee, as well as launch new initiatives, Dr. Hennen said.

Established by the AOA Board of Trustees in October 2008, the center is based in the AOA St. Louis office, with former health insurance plan executive and consultant Maureen West as director. Charles Brownlow, O.D., who has consulted to doctors and others in the eye care arena since 1994, serves as the center’s associate director.

The center will pursue its objectives through programs at the national, local and practice levels, Dr. Hennen said. AOA member optometrists are encouraged to take part in all three, he emphasized.

National programs

The center hopes to begin seeing comprehensive eye examinations included in the benefit packages of several additional major medical plans by as early as 2011.

To that end, the center will launch aggressive efforts to encourage coverage of comprehensive eye examinations in November of this year. Center efforts to monitor emerging health and reimbursement trends will focus largely on three areas: electronic health records (EHRs), health provider quality measurement, and value-based purchasing.

The center’s efforts will entail extensive participation in a wide range of major conferences, including national meetings of vision plans, self-funded insurance plans, and electronic health record developers.

Center representatives are scheduled to take part in conferences on the AMA Current Procedural Terminology (CPT) codes and other billing code systems as well as a series of planned focus groups on systemic disease control.

“Effective representation at these meetings is important in educating other health care professionals on optometry, advocating for full inclusion of optometrists as providers, and ensuring continuing access to optometrists for all Americans,” Dr. Hennen said. “It also allows us to learn of emerging developments in the insurance industry as quickly as possible and promptly relate them to AOA members.”

Regional and local programs

Local carrier policies and coverage decisions often determine which health care services are covered under a health plan, the terms under which those services will be covered, and which practitioners can provide those services under the plan.

For that reason, the AOA has a new system of Third Party Center state coordinators to provide expert advice on all aspects pertaining to third-party payers.

Representing a new volunteer position within organized optometry, the state coordinators are appointed directly by the president of the AOA to make the services of the TPC easily accessible at the local and regional levels. The state coordinators will have direction, training, support and resources from the TPC Executive Committee and related AOA TPC staff.

To qualify as coordinators, optometrists must have extensive background in third-party issues. Many formerly served as state optometric association third-party chairs.

The state coordinators will be charged with:

• Advancing the AOA objectives of quality, accessible eye, vision and related health care for all Americans
• Representing the profession of optometry to insurers, carriers and managed care organizations
• Participating in local or regional organizations that may have a role in shaping coverage
• Educating state optometric association members on third-party eye and vision care programs, including contract details, correct coding, access and provider discrimination issues, and use of AOA resources.
• Monitoring health care trends and issues in their states.
• Assist in resolving issues that arise between state optometric association members and insurance plans.

All of the coordinators’ efforts will center on ensuring participation by optometrists under all public and private insurance plans as providers of a full scope of comprehensive eye care under the same terms and reimbursement schedules as ophthalmologists, Dr. Hennen emphasized.

The state coordinators will take part in regional health care coalitions to promote eye care preventive wellness benefits, he said.

AOA members are encouraged to contact their state coordinators not only to report third-party problems but successes in negotiations on coverage issues with third-party plans, Dr. Hennen emphasized.

Through the state coordinators, the center hopes to compile a library of “best practices” for negotiations with plans, Dr. Hennen said.

In the practice

The AOA Third Party Center will also provide a wide range of resources that will allow AOA members to access and understand the rules that govern insurance reimbursement and file claims correctly. The resouces include:

• AOACodingToday.com, a subscription online coding service, available exclusively to AOA members through Physician Reimbursement Systems, Inc., that provides eight important types of coding information (including ICD-9, CPT, HCPCS, modifiers, associated global information, and local carrier decisions) as well as Medicare rules and regulations in one easy-to-navigate place, with up-to-the-minute changes (www.aoacodingtoday.com).
• AOA Reimbursement Plus®, a second subscription online service that provides up-to-the-minute CPT code reimbursement information; all related CPT code information and characteristics; and state-of-the-art information regarding CPT code and medical record-keeping compliance. Practitioners can enter the CPT codes for the services rendered, the practice’s current fees, the medical carriers that will process claims and the practice’s ZIP code. The system then provides the claims filing rules that apply to the practice (http://aoa.
  reimbursementplus.com/).
• Codes for Optometry, the definitive coding and billing guidebook for optometric practices, providing all diagnosis, procedure, and material codes applicable to optometric practice in a durable perfect-bound book (divided into four sections with both alphabetical and numeric listings for easy use). The volume includes:
• The Physician’s Current Procedural Terminology (CPT) 2010 procedure codes.
• International Classifications of Disease – 9th Edition Clinical Modification (ICD-9) diagnosis codes.
• Health Care Procedural Coding System (HCPCS) material codes and Medicare’s National Correct Coding Initiative (CCI) Edits.
• Medicare’s current Documentation Guidelines for Evaluation and Management Services.

“Helping optometrists and staff to code services and file claims properly is a top priority for the AOA Third Party Center,” Dr. Hennen said. “Over the coming months, the center will introduce new services to help optometrists access the coding rules and regulations necessary to file claims correctly the first time and deal with rejections and refilling when they occur.”

“As the center launches its new five-year initiative to ensure coverage for optometric services at the national level and the new AOA Third Party coordinators set out to ensure coverage at the regional level, we hope all optometrists will take advantage of the coding and billing resources available through the AOA and make efforts to ensure they are filing claims properly in their practices,” Dr. Hennen said.

Managed care Web resources

Managed care resources abound on the AOA’s Web site: The AOA Web site Managed Care and Insurance page (http://www/aoa.org/x4838.xml) is a comprehensive online third-party information source for optometrists. It offers unique features to help practitioners assess and join insurance programs, including:

• The Evaluating a Plan/ Making a Business Decision page (www.aoa.org/x9268.xml) with an extensive list of factors optometrists should check when evaluating an insurance plan.
• The AOA Chair Cost Calculator, an interactive AOA Web site feature, allows optometrists to easily determine a doctor’s average overhead costs per patient visit (www.aoa.org/x9619.xml).
• Medicare physician fee schedule payment rates (http://www.aoa.org/x9619.xml)
• The AOA Optometrist Access Web page (www.aoa.org/x9184.xml), featuring the AOA State Association Managed Care Toolbox – with detailed information on ensuring access to optometric care through insurance plans.
• The AOA Web site Credentialing page (www.aoa.org/x9608.xml), a step-by-step guide that simplifies the process of presenting the credentials required by insurance plans.
• The AOA Medicare Physician Quality Reporting Initiative page (www.aoa.org/x7990.xml), outlining how practitioners can receive bonuses through Medicare’s voluntary quality care reporting program.
• Practitioners evaluating insurance plans may also wish to consult two articles on the Optometry: Journal of the American Optometric Association Web site (www.optometryjaoa.com):
• “Evaluating participation in insurance plans,” by Dr. Hennen outlines the major factors optometrists should consider when determining whether plan participation will be good for patients or practice.
• “Utilizing chair cost to evaluate health plan contract” by Gregory W. Kraupa, O.D., explains why determining the average cost of providing care per patient is essential in determining whether insurance plan reimbursements are adequate to cover practice overhead.
• An audio podcast explaining the insurance plan evaluation process is also available on the Optometry site.