According to the American Optometric Association (AOA), the increased demand for children’s eye care services integrated with health plan coverage starting in January will require many health plans to add optometrists as participating providers. The AOA has six steps to take advantage of coverage expansion.
St. Louis, MO-A pediatric vision health benefit will be integrated with health plan coverage starting in January. According to the American Optometric Association (AOA), increased demand for children’s eye care services will require many health plans to add optometrists as participating providers starting now. Accommodating coverage expansion for ODs will occur in two ways: through new insurance carriers entering the market and offering new health plans (products), or through existing carriers already in the market offering new health plans.
The AOA, through its Third Party Center, has suggested six steps to take advantage of coverage expansion. ODs should:
1. Determine which of your existing health plan and vision plan contracts include an “all-products clause.” These clauses-common in health plan and vision plan contracts with providers-allow the insurance carrier or vision plan company to add new plans/products which typically include new terms and conditions not found in the original provider agreement. Such changes may come through a contract addendum, contract amendment, or simply a notice. Because of these clauses, a health plan may assign a contracted OD to a new provider network and change reimbursement terms even though the changes were not agreed to by the OD. Laws governing all-products clauses vary from state to state, and in 13 states, insurance laws ban the clauses from provider contracts. However, in many states, insurance laws do not apply to vision plans because they are technically not “licensed insurers” in those states.
2.Be aware of new alliances between health plans and vision plans. Many health plans that have not offered vision care services in the past are now contracting with vision plans to cover and administer the exam and materials benefits. A few may contract with a vision plan for a materials-only benefit.
3. Determine whether you are listed as a participating provider in all new plans. Check provider directories of new health plans and new insurance products (both inside and outside the insurance exchanges) by reviewing exchange and health plan Web sites or contact insurance companies directly.
4. Pay attention to prevalent trends: the narrowing of provider networks and/or changes in plan terms or operations, including changes in your reimbursement. Starting in January 2014, have staff carefully review all explanations of benefits (EOBs); take note of claims denied because you are not a participating provider or reimbursement that is lower than in the past.
5. Seek expert help when needed. Doctors should seek out professional assistance from trusted business and legal advisors to fully assess their unique practice situation and address any concerns that may arise during a contract’s review and negotiation.
6. Know what your contracts say. Perform a detailed review of all contracts. This is critical to ensuring that the individual is making smart business decisions and provider agreements are working consistently in his or her best interests. This is especially important when insurance coverage is being expanded to millions more Americans. (A good resource is Power of the Pen, a free PowerPoint tutorial to AOA members.)
Following the review of all contract terms and conditions, including any new requirements being implemented during health care reform, ODs’ options include:
· Negotiate new/different contract terms as needed (if the insurer is willing.)
· Remain in network as a participating provider under the terms of the existing contract.
· Terminate the agreement in accordance with the contract’s termination clause.
· Or elect to not renew with the insurer at the contract’s renewal date.
Ultimately, contract decisions must be based on what each individual OD determines is best for his or her practice. When making decisions about contracts, it is essential to keep in mind that antitrust laws do not allow ODs to act in conjunction with other optometrists who are not part of the same practice.
The AOA Third Party Center offers a variety of resources its members, which may be accessed (member log-in required) at www.aoa.org/x3746.xml.