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How to stop fitting Med Nec CL

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Stacy Vo

Member
Sep 7, 2009
67
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School/Org
New England College of Optometry
City
redlands
State
ca
Hi. I can't find any posts about this so I decided to post the question:
What do you say to patients who have been fitted by you for a few years that you have decided to stop fitting Medically Necessary Contacts? I know I can't say "Your ins does not cover it". Am I obligated to fit them if I'm taking their insurance (EM, VSP, Spectera...)?
Thank you.

Stacy.
 
That’s a tough one. Maybe “grandfather in” your existing patients who expect it, but don’t do it on any new patients.
 
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I'm no guru, but I think that if one agrees to be a provider on any particular panel, then one is obligated to follow all the rules of that panel -- both the ones we like and the ones we don't like.
 
I don't think so. Just because I'm a provider for Blue Cross and I'm licensed to treat glaucoma, doesn't mean I am obligated to treat that patient's glaucoma. I can simply refer them to a provider who does.-Charlie
 
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I agree with Charlie. You can decide you no longer provide that service in your office.If it's something easy like a high minus soft lens and an established patient, I would go ahead and provide the service. Otherwise, no to a losing proposition. For special cases where they have no alternative but you, then I might make exceptions out of a sense of duty.
 
Are we talking high refractive error cases or are we talking free form digital sclerals for advanced keratoconus?

If KCN, and you already did the challenging fit previously, for an established patient, could you continue to care for that patient, but decide not to accept new patients? If you were confident in you prior design, it would seem easy to maintain for the established patient.

I am sure Charlie would agree, these are some of our favorite patients. You can always send them our way. ;)
 
Excellent question! Thanks for bringing it up!

VSP has made it “easy” for us. The rules changed two times last year, I think? And changed reimbursements. And other changes.

I started preparing my patients last year that things were changing and they may no longer qualify.

I printed out the new rules, highlighted the pertinent parts to make sure I have it right, and tell the patient they no longer qualify.

That two line improvement knocks almost everyone off.

Other insurance paid too poorly to make it feasible to take, as far as I looked into it. In those situations, I just never mentioned it.
 
Karen T Walker said:
Excellent question! Thanks for bringing it up!

VSP has made it “easy” for us. The rules changed two times last year, I think? And changed reimbursements. And other changes.

I started preparing my patients last year that things were changing and they may no longer qualify.

I printed out the new rules, highlighted the pertinent parts to make sure I have it right, and tell the patient they no longer qualify.

That two line improvement knocks almost everyone off.

Other insurance paid too poorly to make it feasible to take, as far as I looked into it. In those situations, I just never mentioned it.
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I think that two line improvement refers only to necessary CL when there is an associated medical condition. The VSP necessary CL provision for high myopia and anisometropia not associated with a medical condition does not require the 2 line improvement. That refers only to the higher-reimbursing situation that is associated with medical conditions. At least this was what it was the last time I checked.

But I also agree with Charlie that you can certainly decide to refer out patients who have a condition that you do not want to treat.
 
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Andrew Gore said:
I think that two line improvement refers only to necessary CL when there is an associated medical condition. The VSP necessary CL provision for high myopia and anisometropia not associated with a medical condition does not require the 2 line improvement. That refers only to the higher-reimbursing situation that is associated with medical conditions. At least this was what it was the last time I checked.

But I also agree with Charlie that you can certainly decide to refer out patients who have a condition that you do not want to treat.
Click to expand...
Yes, that’s what the new rules say. K-cone, other ectasia, scarred corneas, etc. need a two line improvement

Basically, I’ll only be fitting high prescription.

Another decision I have made is regarding the cost of the contacts. I match 1-800 in pricing if they have the lens, or msrp at times. If the reimbursement doesn’t give me that much money, (and cover services as well) I will tell them their insurance doesn’t cover it. I’ve heard doctors say sometimes they end up spending more for the lenses than they’re reimbursed. Not me, not anymore. Insurance is a shell game anyway. I’m not playing to lose anymore.
 
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