Last week, I introduced the idea of making time to investigate and evaluate managed care plans and become credentialed with plans that make sense. The tough part is that all plans do not make sense. In this article, I’ll share some thoughts on how to evaluate managed care plans. We’ll start with medical plans and the touch on vision plans.
Do you want to join a medical insurance plan or ACO?
Don’t make the mistake of assuming that all medical plans pay well because they are medical. Some of the newer plans pay so poorly and have so many compliance measures, they make the worst of the vision plans look good. Medical insurance today is moving away from fee for service and entering a world of value-based reimbursement. To measure “value” and “quality”, providers must comply with a host of reporting requirements that can be extremely burdensome, similar to meaningful use and PQRS measures. Compliance can be very time consuming and distracting for staff. There could be financial penalties if accountability is not met. Couple this with low fees for office visits and some plans may not be worth taking.
Will we have to move to this model eventually?
Maybe, but we have seen the health insurance industry and the federal government change their policies fairly often in the past few years. In many cases, we are better off waiting and monitoring a program and not rushing in.
Will you be locked out of a plan?
It seems to me we have been down this road a few times and we should learn a lesson to not act from a place of fear. Many ODs joined low-paying vision plans for fear of being left out and that allowed the vision plan to grow stronger. I would not worry about being locked out. I would join plans quickly if you can find out the details of what they pay and what the value-based requirements are, and if it looks good to you. Otherwise, wait and monitor. If a colleague pressures you to join a certain plan, I would question the true agenda.
If you join a plan, will you get referrals?
Being included on a long list of providers for a health plan does not ensure that you will get referrals of patients from primary care physicians (PCP). Referral patterns from one physician to another develop just as they always have: locally based on relationships. Meeting local physicians is still the best way to cultivate referrals. Doing so will help you to identify which insurance plans you want to become a provider for. Drop in on PCPs in their office to introduce yourself. Joining local community service clubs is another way to meet doctors. Start the referral relationship by sending your patients to certain PCPs along with sending short, concise report letters.
What about vision plans?
There is not one blanket right answer about joining vision plans. It is very market driven and it also depends on the practice model you want to pursue. Not all ODs want to build a large practice. Your acceptance of vision plans may change if you want to bring in an associate OD or open multiple office locations. Some ODs have plenty of patient demand without vision plans (although this is pretty rare).
Most optometrists are misinformed about the profitability of vision plans. If we only look at the exam fee that is offered, most ODs would reject the plan. But if you look at the total revenue and profit produced by the average patient in a vision plan, it is better than you think. Vision plan patients often buy non-covered services like retinal screening tests, multiple pairs of glasses, contact lenses plus glasses, nutritional supplements, optical upgrades and medical eye care. We need to look at the big picture of everything that is collected and the fact that the basic optical lab bill is covered for you. Vision plans can be smart for some practices.
Best wishes for continued success,
Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week
Dr. Gailmard's new book, Practice Management in Optometry: A Blueprint for Success Based on the Optometric Management Tip of the Week, is now available on Amazon.