Article Date: 2/1/2007

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Pick Your Best Plan
Before signing up for a specific vision plan, follow these eight tips to ensure it's the right plan for you.

Dealing with vision plans can be like dealing with an unexpected visit from the black sheep in your family — confusing, daunting, frustrating and time consuming. The good news: While you can't pick your family, you can pick the vision plans best suited for your practice. How? By following the eight tips listed below.

1. Determine your chair costs

To ascertain whether a vision plan is going to fit your own financial needs, figure out your chair costs, says optometrist, Mark Hennen, chairman of the American Optometric Association's (AOA) Eye Care Benefits Center.

"Each plan has its own reimbursement schedule, and you have to know what it costs you to see a patient before you can determine whether you can afford to see a patient on that specific plan," he says. "Once you determine it costs you 'X' to cover the costs of seeing a patient, you know that you need a vision plan that will cover 'Y' so you can actually make money instead of losing it. To achieve this outcome, be aware that you often have to negotiate with the vision plan representative."

Sometimes, optometrists overlook this important step out of fear, Dr. Hennen says. For example: An O.D. finds out that his competitor managed care

signed up for a specific plan, so out of fear of losing money and patients to his competitor, he also decides to sign up for the plan without taking the time to see if the plan makes financial sense for his practice, he says.

"You may think you can make up your financial losses from signing up for this plan through patient volume, but this does not happen. You really have to ask yourself: 'Can I continue to remain in practice and make a profit if I see patients from this plan?' If the answer is 'no,' don't sign up for it."

Another mistake: Signing up for a plan that you know doesn't reimburse you enough because you've got openings in your schedule. "If you do this, your schedule will eventually be full of patients on this specific plan," Dr. Hennen says. "There is absolutely no reason to sign up for a plan that doesn't cover your chair costs."

2. Assess the reimbursement schedule

Once you determine your chair costs, obtain a contract from an array of vision plans, and find out which ones have reimbursement fees and schedules that can support the business side of your practice, says optometrist Douglas C. Morrow, who currently practices in Au-burn, Ind. and has served on the AOA's Eye Care Benefits Committee for several years.

"Look at the reimbursement schedule for both the exam and the optical materials, and determine what kind of profit you can generate from that reimbursement schedule," he says.

Also, find out if the vision plan can unilaterally cut your reimbursement, adds Dr. Hennen. "Let's say the vision plan representative gives you a fee schedule that you are pleased with, but a year from now, that representative informs you that his company is losing money, and as a result, your reimbursement is being cut," he says. "In some vision plan contracts, it says that the company can go ahead and do that. So, you've got to see if that is in the contract."

In addition, some plans require you provide them with your lowest reimbursement rate, Dr. Hennen says. "If you sign a contract with a vision plan that has lower reimbursements than other vision plans you belong to, one of those other vision plans may have a legal right to receive that same low reimbursement due to a clause within the contract," he says. "So, make sure you look for this in the contract as well."

3. Fully understand the plan

In order to obtain reimbursement, you must be able to easily navigate through the plan's rules, says Dr. Hennen. If the plan meets the following three criteria, it will most likely work for you:

• You're familiar with the plan's codes. Vision plans can include several sets of codes, so make sure you are well versed in the codes of a specific plan so you can get reimbursed in a time-ly fashion and avoid appeals, says Dr. Morrow. "Let's say you bill an E&M code to a plan that only accepts 92000 codes. Your submission for reimbursement will get rejected, and while you probably won't lose the fee, the rejection will create a situation in which you'll have to re-bill the plan. This creates a delay in payment."

• Your designated coding staff person can understand it. Make sure the plan isn't going to be an administrative burden, says Dr. Hennen. "You don't want a plan that's going to require your coding person to spend a majority of her time working on when she's got five other plans to take care of as well," he says.

Also, make sure your optical manager can understand the plan, adds Dr. Morrow. "You want this person to make sure the plan is going to meet with your dispensary's requirements," he says. "For instance, if the vision plan requires the use of specific labs and your optical man- ager knows that these labs do not provide the quality of work your patients are used to, you may not want to sign up for this plan."    

• The plan has electronic filing. Electronic filing makes the process of filing for reimbursement more efficient because you don't have to deal with lose papers, and it can reduce your staff turnaround and payment time, says Dr. Morrow. "I've heard some horror stories from colleagues who have had plans that required filing by paper, and these O.D.s ended up waiting 30 to 45 days before getting reimbursement," adds Dr. Hennen. "But, there are plans out there with which you electronically file, and you get paid on a week-ly basis."

In the very near future, all claims will have to be filed electronically, so a plan that already has this feature will be ahead of the game in terms of the service they provide to you and your colleagues.

4. Examine the plan's appeal rights and process

You need to know what you can and can't file and what you might have to give up — in terms of services that you can provide and bill — by joining the plan, says Dr. Morrow. "And, you need to know how long the appeal process is going to take if you do bill something in error," he says. "You may even want to ask the vision plan representative to send you statistics on the amount of claims rejected, the number of appeals that receive reimbursement and the company's turn-around time on reimbursement."

An example of a filing problem that often leads to an appeal: If the plan covers an annual visit or an every two-year visit, you need to know whether that coverage is based upon the date of the patient's last visit or whether it's a calendar year benefit, says Randolph Brooks, O.D., of Ledgewood, N.J., and former chairman of the AOA's Eye Care Benefits committee.

"Many times optometrists get into trouble because they have a patient come in, in 50 or 51 weeks, and the patient has a benefit coverage that does not go into effect until a full year has elapsed since his last appointment. So, if a patient moves up an appointment a week or two, you may find he is not covered, and you will not get reimbursed for the exam."

The bottom line: If, for any reason, after reading this part of the contract, you don't agree with the company's appeal rights and process, don't sign up for the plan, says Dr. Hennen.


5. Examine the penalties for dissolving the contract

Although the plan may look good now, you need to be prepared for a situation in which you may want to dissolve your contract. So, find out what type of penalties the plan imposes, should you eventually decide you want out, says Dr. Hennen.

Also, know how easy it is to get out of a plan, how much notice is required, and if you decide to terminate your membership in a plan, make sure the vision plan company actually does so by checking its Web site, adds Dr. Brooks. "The last thing you want is to have a family show up for appointments because you are listed on the Web site of a plan that you dropped three years ago," he says.

6. Determine the frequency of audits

Find out how frequently the vision plan company conducts audits and what they entail, says Dr. Hennen. "You are not trying to cheat anyone or get out of an audit; it's just that audits can be a burden, as they can take you away from your patients and your staff away from their duties," he says. "So, you want to know if the company in question is going to conduct a simple utilization and review process in which it has someone come to your practice, pull charts and audit them themselves, or if you and your staff have to pull all the information together for that person. Most O.D.s want the former scenario."

Still, the fact that the company does audits indicates the plan is of high quality because the vision plan company is looking to maintain some quality control measures for the provid-ers, adds Dr. Morrow. "If the vision plan company doesn't do any audits, I think you have to question how serious it is at providing the quality care they need to, to provide for the plan," he says.

7. Identify a link between the vision plan and a medical plan

Know whether the vision plan is associated with the patient's medical plan because you'll need to look carefully at his medical plan to determine what's covered, to see if joining the vision plan makes sense for your practice, says Dr. Brooks.

"Some medical plans offer a routine vision benefit as part of their plan while others outsource that benefit to an outside vision plan. It makes especially good sense to be able to provide vision care for those patients to whom you are delivering medical care, as long as the plan meets all of your other criteria," he says. "Conversely, don't sign up for a vision plan that makes no sense for your practice just because you think that it may help you get on their medical panel."

8 Avoid anti-trust issues

You can discuss whether a vision plan is the right fit for your practice with your financial advisors, staff, accountant, attorney and fellow practitioners within your practice, but you can't discuss such decisions with your colleagues who aren't part of your practice, says Dr. Brooks.

"If you discuss a particular vision plan with optometrists outside your practice, and you all decide not to sign up for that plan, this will look like you are boycotting that plan once the vision plan company receives letters from all of you within the same vicinity," he says. "This is against anti-trust laws in every state."

Remember: While you can't pick your family, you can pick your vision plan. And by following the eight tips above, you at least have the power to make this aspect of your life less confusing, daunting, frustrating and time consuming. Those pesky relatives, however; they're another story.

Your Patient's Vision Plan Satisfaction Can Affect You

In early November 2006, J.D. Power and Associates, an organization that conducts quality and customer satisfaction research based on survey responses, revealed the results of its second National Vision Plan Member Satisfaction Study. While the study weighs the satisfaction of national vision plan members, believe it or not, you play a role as well.

"While many patients recognize that doctors aren't employed by the vision plan, we know from other research with health plans that some patients do tend to view doctors and the plans to which they belong similarly," explains David Stefan, executive director, healthcare, J.D. Power and Associates. "So, since some patients look to optometrists as their ally and agent in vision care, their satisfaction with their eye doctor and their vision plans may affect one another."

A total of 2,011 respondents, ages 18 and older, who had an eye exam in the previous 12 months were culled from a cross-section of the U.S. Census Bureau's population statistics and rated their preferences based on five performance factors of the study. They are listed here in order of importance, according to respondents:

• Coverage and communication (40%)
• Cost (25%)
• Eye doctor network and clinical service (22%)
• Eye wear purchase experience (8%)
• Customer service support (5%).

"Coverage and communication deals primarily with how often exams are covered and how often spectacle and contact lens purchases are covered, among other coverage issues. This factor also encompasses communication issues about coverage," says Mr. Stefan. "The results of this

year's study show that patients are substantially dissatisfied with communication from their vision plans about benefits and services and the ease of understanding those benefits."

So, how can you prevent this from affecting your practice?

Since you and your staff discuss your recommendations for your patient's vision care in terms of spectacles and contact lens selection, be aware of that patient's vision plan coverage. This way, you can talk to the patient about the relative cost and savings of his plan, which helps him make an economical purchase, says Mr. Stefan. And should the patient not be satisfied with the plan's coverage, he will be satisfied with the service you and your staff provided in explaining the plan to him.

"What was really interesting about this study is that we found that feedback at the time of purchase on savings as a result of being a member of a plan strongly impacted satisfaction," Mr. Stefan explains. "If people got a verbal summary of their savings, they became more satisfied, a written summary of their savings made them even more satisfied, and if they got both a verbal and written summary, they were the most satisfied. We also found this in our retailer study in which we tested savings statements overall — not in connection with plan membership."

Obviously, it's the vision plan's responsibility to effectively communicate its value to its members, but this study shows this is not happening. And like it or not, many patients do associate you with the plans you accept. So, think about how you can help vision plan members better understand their benefits. After all, if they don't see the value in the plan itself, they will see the value in you as their practitioner.



Optometric Management, Issue: February 2007