We use the term “scope of practice” to describe all the services that an OD can legally provide, but equally important is that an optometrist be reimbursed for providing those services. Let’s call this “scope of payment.”
Central to scope of payment is becoming a provider for one or more of the medical insurance plans. This enables the optometrist to increase patient access to their practice and to be reimbursed for the care they provide.
In most cases, joining medical insurance panels today is not difficult. Specifically, it can be done by contacting the medical insurance plan and requesting a provider contract and fee schedule. This is thanks to advances in optometric education and training, along with the persistent efforts of the American Optometric Association (AOA) and state-affiliate optometric associations to educate the medical insurance industry on the profession’s full skill set and of the benefits to adding optometrists as medical insurance panel providers.
That said, 2 main hurdles remain for ODs to access medical insurance panels. In this article, I address scope of payment and ways for optometrists to ensure that they can be reimbursed for all the services that they provide.
Hurdle 1: Licensure and Credentials
The health care delivery system places value on health care providers, including optometrists who practice to “top of license.” This translates to having malpractice insurance, a National Provider Identifier number for processing health insurance claims (ODs can apply for one at https://nppes.cms.hhs.gov/login), and an unlimited license to practice in their state, including all training and certifications. OD’s who have questions about the status of their licensure can contact their state department of health/board of optometry and their state optometric
association.
As an example, many medical insurance panels look for an optometrist’s participation in Medicare as a bell weather of their worthiness to participate in their own provider panel. This is due to Medicare’s rigor in vetting an OD’s credentials to join its provider panel. Medical insurers also require this credential as a condition for participation with its own Medicare Advantage Provider Panel. The same is true with respect to Medicaid and managed Medicaid programs.
To facilitate applying for medical insurance company participation, the Council for Affordable Quality Healthcare (CAQH) enables the health care provider to upload and store their professional credentials. This can be accomplished via the CAQH ProView platform, which is accessible at https://www.caqh.org/providers. The CAQH is a nonprofit alliance whose goal is to streamline and simplify health care administration.
A caveat: If ODs join a provider panel as part of a larger group (ie, joining a group practice) and not as an individual, it will be necessary to reapply for all their health plan credentials if they leave that group.
Hurdle 2: Closed Panels
It is possible that a health insurer does not have an “open panel.” Among the many reasons for insurers to close their panels is that they have enough providers in a given geographic area. In this case, upon submitting the application the OD may receive a “closed panel” rejection letter. But this does not mean that there is no way to gain panel access.
If the optometrist is faced with this possibility, I recommend they contact their state optometric association for assistance. The state optometric association should know, for example, whether their state has laws that can assist the OD in gaining access to medical insurance panels. Additionally, the state optometric association may have helpful information about how other optometrists have dealt with the closed panel challenge.
Other possibilities are to collect data that support the need to increase patient access in the optometrist’s geographic area, enlisting patients and/or health care provider colleagues to provide letters of support for their application to become a provider, and personal meetings with the leadership of the plans.
Regarding the data, this can include the number of eyecare providers in the optometrist’s region—both optometrists and ophthalmologists—the services that the OD provides, or unique aspects of their practice (eg, hours of operation, specialty contact lenses, low vision, vision therapy, etc).
In terms of enlisting patients and/or health care provider colleagues to help, the optometrist can ask them for letters that support the need for the OD’s services.
Finally, the optometrist may also ask for a one-on-one meeting with the plan’s medical director, director of network management, or director of provider relations to present the compelling information that supports their request.
The goal is to demonstrate a need for improved access to the care that the optometrist provides or to show they provide a unique service. Detailing a deficit in access to care or the unique things the OD provides may compel the medical insurer to add them to the panel.
Get on the Panels
In recent years, we have heard a seemingly new phrase, “medical optometry.” I would argue that a more appropriate phrase is “comprehensive optometry.” Why? Because optometrists are remarkably skilled in many aspects of eye care. And it is the sum of all of those things that equals the comprehensive practice of optometry. So, whether ODs focus their practice on fitting complex contact lenses, providing low vision services, managing complex medical eye conditions, or surgical procedures, they are practicing optometry. Therefore, a comprehensive approach to the practice of optometry equals comprehensive optometry.
All this speaks to what ODs can legally do within the scope of their licensure (scope of practice). But to be successful, optometrists also need to be paid (scope of payment) for providing “comprehensive optometry.” Access to medical insurance panels is one way to achieve this. I hope the action steps that correspond with the 2 hurdles discussed enable my optometry colleagues to do just that. OM
