EYECARE: Managed Care Firms Help Tackle Complexities of Managed Vision Care By Mark Tosh Monday, October 16, 2017 12:25 AM Health care can be a fast-paced, highly regulated marketplace, which requires companies in this business segment to be nimble, innovative and strategic. This also holds true for the companies—both longtime players and innovative startups—in the narrower business of managed vision care. New regulations and quality measures for health plans, technology advances on both the provider and plan side and the overall changes in the health plan marketplace have combined to present new and greater challenges for eyecare professionals and their health plan partners. These challenges and opportunities come against a backdrop of growth in the vision benefit market. According to one survey, enrollment in vision benefits over a five-year period earlier this decade increased nearly 20 percent. And, health plan data indicates that more than 8 out of 10 employers now offer a vision benefit as part of a standard benefit package. In addition, The Vision Council has found that 75 percent of all patients who receive an eye exam are enrolled in a vision plan, which indicates the influence vision benefits play in driving regular vision care. The new quality measurements are setting the agenda for many in eyecare. For example, one of the lowest-performing Healthcare Effectiveness Data and Information Set (HEDIS) quality measures for health plans is the rate of compliance with diabetic eye exams. (HEDIS is a tool used by more than 90 percent of America’s health plans to measure performance on care and service measures.) The challenge for companies is to develop programs that improve both patient outcomes and health plan reimbursements. Following are just a few examples of companies that are working with health plans and providers to change the look of how things are done in the new managed vision care segment. Premier Eye Care: Focusing on Tech Solutions to Help Providers and Plans Navigate New Landscape TAMPA, Fla.—In managed vision care, technology—as it has done in just about every business—has brought major change to the old way of doing things across the administrative and operations processes. As a result, many pieces of the managed vision care process have moved from a heavy emphasis on customer service-type roles, which are still very important, to more of a high-tech function. “We’ve seen the world really change in our industry,” said Lorna Taylor, chief executive officer of Premier Eye Care of Tampa, Fla. “We look at this as if we were really driven by customer service for the first 15 to 18 years [of our existence]. But, over the past seven, eight or nine years, as regulations increased and the auditing requirements have become even more important, we’ve really evolved into more of a technology company.” She added, “What we do in technology is very much driven by the needs of the health plans and the needs of the providers so that they are getting excellent responses and grades from the members we are all serving.” Premier Eye Care, founded in 1994, also has offices in Boca Raton, Fla., and Honolulu, and generally is acknowledged by its partners as being among the national leaders in providing innovative solutions for managed medical and routine eyecare. “We’re part of big data now,” said Jason Panos, Premier’s chief operating officer. “We have all the different data sources come in from the various sources, and it’s really an overwhelming amount of data coming in. Our strength lies in the fact that we’re able to take all those different data sources and places… and really consolidate this down to a more simple and usable format.” Premier manages hundreds of unique vision plans for its partner health plans and, via an expansive network of providers, it assists in delivering exams, eyeglasses and contact lenses to members insured by these health plan partners. The company also boasts a highly skilled work force that enables Premier to deliver to both health plans and providers a robust program for HEDIS, or Healthcare Effectiveness Data and Information Set. It has helped its partners consistently achieve 4 and 5 stars on the eye-related measurement indicators, according to the company. “The only way we can achieve the results in the quality requirements is by setting up innovative solutions that are user-friendly for our providers,” Panos said in a recent interview. In its operations, Premier has become recognized for its focus on both technology and corporate culture. Taylor works to encourage associate engagement through an organizational model that encourages innovation and self-direction, and as a result she was named earlier this year as a finalist for EY’s Entrepreneur Of The Year 2017 Award in Florida. Premier, which has been ranked as one of Florida’s fastest-growing companies for the past two years by the Florida Business Journals, has now established operations in seven states and tripled its revenue over the 2012-2016 time frame. Taylor has managed Premier with a focus on the “triple bottom line: people, planet and profit,” according to the company. Premier Eye Care also has received various “certifications” for its work with health plans and providers. In January, the company received Certification for Utilization Management and Credentialing from the National Committee for Quality Assurance (NCQA). This certification is a quality assessment program that focuses on consumer protection and customer service improvement, and it is designed to reduce the level of review and information gathering required for current or future health care partners to do business with Premier, according to the announcement of the award. It marked the second consecutive time Premier has received this certification, having first earned the certification in December 2014. The company was recertified in December 2016 and earned a 100 percent score in both Utilization Management and Credentialing. illuma Care Connections: Helping ECPs Fill the Care Gap for Diabetic Patients ATLANTA—illuma Care Connections, a care coordination company, was founded in 2016 to offer services to health plans and ECPs that address many of the changes taking place across health care. As part of this mission, illuma’s services are designed to improve outcomes, reduce costs and drive practice growth by ensuring that patients with known vision risks are scheduled for the appropriate exams with ECPs in the illuma network. The company also is set up to integrate care coordination services and HIPAA compliant clinical data workflows into independent practices, one of the keys to bringing greater efficiency and quality to health care. As an example of illuma’s efforts within diabetes, in September the company announced a partnership with Professional Eyecare Resource Co-Operative (PERC) and Infinity Vision Alliance (IVA) to address a care gap among the diabetic patient population. The goal is to engage identified diabetic patients and schedule appointments with providers so they can receive the necessary dilated eye exams. This effort also brings independent ECPs “into the mainstream health care marketplace and improves quality scores for health plans,” illuma said at the time of the partnership announcement. Diabetes is the leading cause of blindness among adults in the U.S., and regularly scheduled dilated eye exams are an important piece of preventative care and chronic condition management. Compliance with these exams is a key metric health plans use to measure quality and develop quality improvement programs. At the time illuma was founded, “health plans were looking at ways they could share risk with providers across the board,” chief executive officer Stephen Kendig told VM. “In order to do that, they need to have different systems in place to look at clinical and billing data differently,” he explained. At the same time, health plans and providers are being evaluated on the outcomes their patients achieve. “People are saying that not only do providers have to take risks in terms of their fee structure, now they are being measured on how healthy their patients are,” Kendig said, noting that health plans, too, face this same measurement scrutiny. Here are a few ways in which illuma works across health care: for ECPs, illuma’s “Care Coordinators” are able to create appointments for patients with high-risk medical conditions, which ensures standards of care are maintained. For diabetic patients, current standards of care and HEDIS/Star program requirements state that diabetics need an annual dilated eye exam. illuma Care Coordinators work with local health plans to make sure that members get these exams. “We thought this would be the time to bring optometry to the forefront and help them practice to the top of their license,” Kendig said. “So we found this huge opportunity existed within the diabetes condition group so [what we are trying to do is] drive diabetic eyecare.” Kendig also noted that illuma is in the market “championing the optometrist and helping them work more closely with ophthalmology.” The goal is to help ophthalmologists address the surgical and disease management work, while optometry “is more at the front line of eyecare and doing a lot of the screenings and preventive care,” Kendig said. Another area of emphasis for illuma is to address the confusion that exists across patient groups related to vision care and medical eyecare. This could result with an increase in the scope of optometry to be more of a health care provider. “Getting that message out there is going to take time,” Kendig said. “But we are going to keep shouting it from the hilltops.” illuma works with all types of insurance plans, including traditional commercial, Medicare, Medicaid and marketplace. AssureAbility: Experts in a Changing World of Health Plans, Vision Benefits and Government Regulations GREEN BAY, Wis.—Paperwork, in any profession, often is a hurdle that gets in the way and slows the process of doing the real work. That was part of the rationale two longtime optical industry executives—Adam Cherry and Amy Kraemer—had in mind when they founded AssureAbility Inc. here about five years ago. Cherry also is the president of the independent lab Cherry Optical in Green Bay, and Kraemer has held positions in administration, training and insurance contracting for private practice optometry during her time in the optical business. Both Cherry and Kraemer drew upon the experience of their regular day jobs and the feedback Cherry received from his lab reps who were calling on optical practices. “Our sense was that there was a need for specialized services,” Kraemer said. “A lot of practices have what are called in-house billers or the insurance department… but there is no formal training or education for that and a lot of it is ‘learn as you go,’” she explained. At this time, Kraemer also served on some state and national association committees that allowed her to build up a network of contacts across the business. She also began lecturing on coding and billing, and other aspects of managed vision care. “When Adam and I came together [to launch AssureAbility], he had the business side of things and I had the hands-on communication with the actual practices, and it just seemed like a good fit,” Kraemer said. Today, AssureAbility has flourished to become an important claims management and consulting service that operates on the belief that the primary focus of health care providers, including ECPs, should be patient care, not paperwork. The firm provides audit reviews, claims management, revenue-cycle management, eligibility verification and other consulting services either via packaged programs or select individual as-needed services. It uses a remote connection system that runs from a workstation within a client’s practice and utilizes the systems that a practice already has in place. “Our expertise lies in helping practices thrive in the ever-changing world of insurance payers, vision plans and government regulations,” Kraemer added. And the business of managed vision care continues to evolve as new technology and new health plan programs become bigger factors. Kraemer said the business has gotten both more complex and more efficient over the past several years. “The implementation of electronic medical records (EMRs) and the various practice management software systems that go along with that were intended to make things better, and make medical records documentation easier,” she said. “In some ways this has [happened], but to make one area easier it has made other areas more difficult.” For example, she said, the new systems haven’t increased the volume of patients that a practice can see. Future opportunities for AssureAbility include adding news business with the “next private practice in need of help, and there are so many of them out there,” Kraemer said. Other opportunities include expanding the current menu of services (with tools for managing quality payment programs) to allow providers to increase their focus on patient care. “As I talk to providers about their needs and their practice goals, I try to remind them that the decisions they made yesterday may need to be readdressed today,” she said. “Because in the world of insurance, the regulations and the policies are constantly changing.” Patch: Helping ECPs Deal With Out-of-Network Patients SAN FRANCISCO—There are possibly thousands of technology startups that emerge in the health care marketplace every year, and just about everyone is looking to hit upon an idea that breaks new ground for its user base. Patch, a San Francisco-based startup, counts itself among the new businesses that believes it has hit upon a unique approach to solving a longstanding health care problem. Patch, on its website, calls itself “the first universal platform for vision care that manages patient eligibility and claim filing for out-of-network vision plans in one simple application.” “We found that right now the method for being able to figure out what people’s benefits are and help them to understand them—and the difference between in and out of network and filing for reimbursements at the point-of-sale—is a really complex process,” said Patch co-founder and chief executive officer Brett Plotzker. “It’s sort of unnecessarily complex and we wanted to make it simpler.” Plotzker, whose background is in quantitative stock trading and tech startups such as SMS Assist, and his co-founder Jeremy Bluvol met while they both were MBA students in Tel Aviv, Israel. Bluvol has a background in biomedical engineering and has done work with everything from ultrasound technologies for cancer detection to launching a genetic testing company. The goal for Patch, according to Plotzker, is to help ECPs dealing with out-of-network patients in a few different ways. First, for ECPs who have chosen to operate without participating in managed vision care plans, the Patch system and process enables them to “facilitate reimbursements for their patients without actually having to take the insurance,” he said. In addition, the Patch system also helps ECPs by lowering the administrative aspect related to out-of-network patients, reducing the ambiguity, moves the reimbursement process to a digital environment and helps ECPs operate their practice more efficiently. He said behind the unmet need that prompted the partners to develop their idea is the fact that digital is transforming conventional marketing approaches, leading to optometry practices that rely more on social media comments and reviews on sites such as Yelp!, Google and Facebook to retain and acquire new patients. “People are becoming less reliant on the [managed vision] network and the out-of-network aspect of eyecare is becoming greater,” he said. The Patch founders saw this as an opportunity “to solve a problem that wasn’t so obvious a few years ago.” The core part of Patch’s model is to play the role of tech innovator in the managed vision care sector and to provide a unique ability to integrate core insurance features into traditional e-commerce and in-practice workflows. This allows ECPs to serve patients faster, and to ensure a more positive experience when dealing with out-of-network benefits. Plotzker said Patch has developed marketing materials for ECPs to use in their practice to promote their out-of-network capabilities and that the company has established business relationships with ECPs in 42 states, primarily independents. “We haven’t started working with any of the bigger groups yet, but a lot of people have gotten in touch with us,” he said. The Patch platform, which is a web app, employs “bank-level security and is fully HIPAA compliant,” according to the company’s website. Users can simply sign in using their browser. “Our onboarding process is real fast,” Plotzker said. “We have had clients who have signed up and then have been up and running in five minutes.” Looking ahead, Plotzker said Patch executives “see a use case in almost every practice” and that the company’s next milestone is to have more than 1,000 providers on board. This could happen within the next six to 12 months, he noted. “Really, the most important thing for us is delivering value to people and people seeing the value of our product,” he added.