How to stop fitting Med Nec CL

[Stacy Vo]

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.

 

[Mike Alvarez]

That’s a tough one. Maybe “grandfather in” your existing patients who expect it, but don’t do it on any new patients.

 

[Andrew Gore]

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.

 

[Charles A McBride]

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

 

[A A Camblor]

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.

 

[Joe DiGiorgio O.D.]

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.

 

[Karen T Walker]

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.

 

[Andrew Gore]

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.

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.

 

[Karen T Walker]

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.

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.

 

[Andrew Gore]

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.

I’ve heard doctors say sometimes they end up spending more for the lenses than they’re reimbursed.

Oh yes, it's SO VEXING!

 

[Jeffrey Kiener]

https://www.eyeconic.com/help-me/we...Mcb76cNnFKksVAmmS3UaAoQLEALw_wcB&gclsrc=aw.ds

 

[Jeffrey Kiener]

https://www.contactsdirect.com/eyem...79DTQnJFBr1kH9m3jbw8LBsZmrJIco_PZq5tpiukN6gl#

 

[Matt Judd]

when I bought this practice I sent every single one of them packing. they were doing a fair amount of hybrid contact lenses (and 50% had outstanding balances) and the higher Rx ones.

I simply had my staff tell the patients we are not a contact lens focused office (true) and sent them to a provider down the street

sidenote: any patient whose insurance doesnt pay and they dont personally ever say a word about it, meaning they received essentially free care, I have zero respect for them.

 

[David Carlton]

View attachment 46882

Oh yes, it's SO VEXING!

Call VSP and state your opinion every Week

 

[David Carlton]

https://www.eyeconic.com/help-me/we...Mcb76cNnFKksVAmmS3UaAoQLEALw_wcB&gclsrc=aw.ds

These ads go out to the subscriber base, would that be seen as competition against the provider panel?

 

[Richard S. Stewart]

I've posted this several times on various sites. With Eyemed I don't even order, much less dispense any ncl's until paid. Been f'd one too many times with them.

 

[Shaune Wallace]

Theses ads go out to the subscriber base, would that be seen as competition against the provider panel?

Good question. Another step in controlling the entire market. The questions lawmakers should ask is if this lowers prices and improves quality of vision care. I venture that it does not, not in the long term.

 

[David Carlton]

https://www.contactsdirect.com/eyem...79DTQnJFBr1kH9m3jbw8LBsZmrJIco_PZq5tpiukN6gl#

EyeMed is playing the same game, interesting, why is the profession accepting this from theses plans. Call them state your pro or con opinion!

 

[Richard S. Stewart]

https://www.contactsdirect.com/eyem...79DTQnJFBr1kH9m3jbw8LBsZmrJIco_PZq5tpiukN6gl#

I looked at the Biotrue price on that site since I do a lot of B&L. I am $100 cheaper than their discounted price and I have a $200 rebate, so $300 less on an annual supply. On Infuse I am $180 less than their best price and a $300 rebate, so $480 less on a year supply. Seems pretty easy to compete against this site.

 

[Matthew Mitchell]

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

I agree with this approach. What I don’t agree with is doing the work and billing the patient b/c the reimbursement from 3P is too low or the provider is too lazy to actually learn how to bill it appropriately. I see that quite a bit and have even seen people seemingly advocate for this on ODW. Not good.

 

[Charles A McBride]

I agree with this approach. What I don’t agree with is doing the work and billing the patient b/c the reimbursement from 3P is too low or the provider is too lazy to actually learn how to bill it appropriately. I see that quite a bit and have even seen people seemingly advocate for this on ODW. Not good.

I don't want to hijack this thread thread so I'll start another called Improper Billing for Med Nec Contact Lenses. Let's suss this out. -Charlie

 

[Patti Richard]

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.

Hi- I’m hats interesting.. I was on with. SP this morning and I want to know if patients need to pay ANYTHING, especially when our time and COGs exceed their coverage. I do charge for all follow ups to medical insurance, but VSP only allows us to use “bundled” codes which isn’t fair! Can you share your secret? Thanks!

 

[Steven Faith OD FAAO]

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.

Stacy, here's what a large VSP practice north of you does in these situations and has done for many years. First, we only deal with VSP so cannot speak to Eyemed, MES, Spectera, Superior, Davis, Block, etc.

The info you need for VSP VNCL and VNCL Specialty is on pages 46-54 in the VSP provider manual. If you are a VSP network doctor you cannot remove or reduce the benefits that a VSP member is allowed through their employer's contract. If you do not want to fit the patient with their eligible CL benefits, you do not have to. But the patient has the right to seek care at a provider who does.

We know what our maximum reimbursements are with the two categories of VNCL. It is only the VNCL Specialty category that requires the 2 line improvement in VA. If you don't know the reimbursement maximums, look a the pages in the manual listed above.

Remember, the professional fees you include with your VNCL are for only 90 days of f/u care. Beyond 90 days, you can charge what is appropriate for the care of that patient and it is a private matter between you and the patient.

For example - We needed to change our normal CL patient fitting mindset when dealing with VNCL. We know our COGS with CLs. We have plenty of patients who are wearing Proclear or Clariti Sphere and not DT1 due to the costs of the materials of DT1 and their VSP VNCL coverage hitting the $750 cap on the VNCL reimbursement. If the patient doesn't do well with this lower level daily then we will refit the patient, after 90 days, with the appropriate associated professional fee.

Honestly, in an office like ours, we see less than ~2% of our VSP patients with this issue and frustration. We see, we fit, we move on to the next patient.