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.
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
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
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.
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
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.
"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
Optometric Management, Issue: February 2007