Independent ODs Voice Concerns About Managed Care's New Rules



Independent optometrists explain how they are reacting to the changes and challenges being presented by third party payers.

Mark H. Rinkov, OD
Rinkov Eyecare Centers

Columbus, Ohio


“Third party payers are restricting what tests may be performed and reimbursed, controlling what care a licensed OD can provide. They are also dictating discounts the OD must provide the patient, not only on the glasses provided under the vision care plan, but also on additional glasses not provided through their plan. They are also dictating the lab they own or have a “contract with.”

We will probably need to see more patients in a day due to low reimbursements. Do we continue to work harder for less?”

Tommy Lim, OD
Berryessa Optometry

San Jose, Calif.

“ODs are forced by some vision plans to use certain optical laboratories. ODs use the lab of their choice for a reason, usually because of trust that the work done will be of a certain high level. I am very unhappy about this but have not yet figured out how to get around this. In California, with private pay patients dwindling and the number of major vision plans down to two or three, we have limited options.”

Chad Fleming, OD, FAAO
Wichita Optometry


Wichita, Kan.

“In updated third party reimbursements in 2014, we have noticed a decrease in medical health insurance providers carrying a “routine” ophthalmic exam. We are still waiting on how they will provide this much needed service to policyholders. Most medical insurances have reimbursed at a level equal to our usual and customary charges, allowing us to continue providing very thorough comprehensive routine care. In response to companies that have substituted their routine medical vision coverage with a vision benefit plan that reimburses at 50 percent to 60 percent less, we have responded to this based on being a medically oriented practice which allows us to continue to bill the medical insurance.

In response to much lower reimbursements we are looking at ways to be more efficient and utilize vision benefits as truly just vision benefits and then recalling them for any medical findings. As we have always done, we will bill the medical insurance for the medical diagnosis and management.

Anticipating more pediatric patients, we are making changes in the dispensary to improve selection. We brought in Ashley Blasi, OD, approximately three years ago, and she specializes in children’s vision. We anticipate significant growth in her schedule. I would recommend any doctor to consider a children’s vision associate. Pediatric vision is a key component for future growth of your practice under the third party changes to meet government regulations.

The main challenge is moving from doing everything for vision needs and eye health needs in one exam. A comprehensive eye exam may become less prevalent as the problem-focused approach to eyecare appears to be the direction managed vision care is pointing toward. Doctors who have already adapted this approach will find themselves ahead of the curve.”

Darren Horndasch
Wisconsin Vision, Inc.

Eye Boutique, Inc.

New Berlin, Wis.

“Third party has represented a large share of our business for many years, a way to attract patients without retail marketing. However, as managed vision care has expanded, it is still necessary to reinforce our message through retail marketing.

All managed vision care plans are fighting to attract new customers, often at the expense of their competitors. The primary means of doing this is to either enrich the benefits offered and/or decrease the premiums charged. The plan then goes back to its providers and asks for reductions in reimbursements, “share” programs, claim processing reimbursement programs and/or the scheduling of items not typically covered, such as anti-reflective, photochromics, high index, etc. to minimize the patient’s out-of-pocket expense. All this is under the premise that we will see new business. This is not new business but business we have earned over the years through their competitors.

In addition, we have seen managed vision plans directing their members to their own labs, contact lens sites and frame programs. This has forced us to review the product offerings, go back to our vendors for increased discounts, focus on specific benchmarks, and look for other items to sell (e.g. medical).

With the ACA and the new pediatric provision, plans associated with insurance companies are approaching us with the premise that since we will see new business, a reduction in reimbursements is once again appropriate for all vision plan participants. Our response has to be to do our best to mitigate the reductions. We must research our claim activity to respond in a manner that is acceptable without losing the opportunity to participate. This will become a larger challenge as plans fight for membership.

There is no standard for reimbursement in the industry. Once we negotiate a contract with a plan they themselves often have a difficult time paying us correctly. The key is to have highly trained, specialized staff that understand the agreements and have key contacts at the plans in the event reimbursements are incorrect. Solid technology that can calculate the algorithms of the agreements correctly is vital.

I find it very important to be actively involved with the principals within the managed care organizations. This allows for better communication outlining what we bring besides just locations. It is a story about how we can help them grow/maintain their business, a key element in a ‘partnership.’”

Eric M. White, OD
Complete Family Vision Care

San Diego, Calif.


“Third party payers are fighting it out to get our patients, some trying to take our patients for their optical chains, going as far as sending coupons to our patients to get their eyewear elsewhere but do the exam, at a reduced cost, with us. I look at this as an opportunity. We need to build a concierge style practice, do whatever is needed to make patients feel like family, give them the best product at a competitive price, e-mail them a personal thank you note.

The medical side is another place for changes. Patients notice if you’re keeping up with new technology.

Doctor-driven dispensing is crucial. Patients don’t know what they need and what they want. They think they just need a new pair of glasses and it will be free. I prescribe to them exactly what they need to make their life more comfortable. If you take the time to explain what and why they need something they will get it the majority of the time. This is why my digital lens sales are over 95 percent, my anti-reflective is over 90 percent, and my Transitions are mostly over 40 percent.”

Gina M. Wesley OD, MS, FAAO
Complete Eye Care of Medina

Medina, Minn.

“We are anticipating an influx of patients due to the Affordable Care Act, and we are preparing to handle that flow as well as be well versed on how those benefits work. Additionally, we plan on fully analyzing how in-office efficiencies can be improved to ensure the clinic is profitable with potentially lower reimbursements.

There is always the challenge of providing a level of care that can be adequately compensated for in reimbursements. That is a decision every provider has to make with each plan. We’ve incorporated more private pay testing, which allows each patient to select premium care at their own discretion, knowing that if they don’t, they are still receiving high quality eyecare. Expanding specialty contact lens fittings has improved revenues regardless of managed care coverage.”

April Jasper, OD, FAAO
Advanced Eyecare Specialists

West Palm Beach, Fla.


“Changes in coverage are always an issue, and changes in deductibles are increasing as well. The best way to take exceptional care of patients in response to these coverage changes is to do our homework ahead of time. Get all insurance information from patients before the appointment, verify coverage, and then go over the benefits with the patient before providing the service. In our office, we collect all fees at the time of the service so there is no issue with accounts receivable.

All of us will face decreased reimbursements. As business owners we need to make good business decisions. If reimbursements do not support our time, we must decide whether to continue doing business with those plans. The days of walking into the office and simply “seeing patients” are gone. To continue to care for our patients and change their lives, we must make certain we stay in business.”

Jason Trucano
Brevier Optical

Excelsior, Minn.

“Managed vision plans are the biggest challenge we face today. The standardization of optometric practices they impose has helped to commoditize eyecare and the services/products we provide. The administration of each plan has also caused much confusion and frustration for staff given the uniqueness and complexity of each plan.

As a general, community-based eyecare practice, we see the decrease in reimbursements as a big obstacle. As reimbursements drop, our ability to survive will depend on volume and our ability to see more patients per hour. With reimbursement fees in flux, investing in the latest technology for the exam lane has also become challenging. Instead, we focus on using technology to gain practice efficiencies to help us do more with less.

We have begun regular reviews of each plan to determine whether to continue to accept them. While the lure of additional patients is enticing, we need to ensure we attract a patient base that allows us to continue providing the highest level of service possible.” ■