We sent a copy of a this letter to one of the few remaining ERISA self-funded plan which still refuses to pay optometrists for medical eye care for their employees. We share it here in the hope that if there are any other similar plans of which we are not aware, that optometrists will take action to challenge their policy. Feel free to use part or all of this letter as needed. It is our sincere hope that there will be very few times optometrists will have to send such a letter, but with the ACA and Harkin Amendment’s future in question, as a profession we have to remain vigilant lest we lose the hard-fought ground we have gained.
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Per our conversation earlier today, I appreciate the opportunity to provide you with information about the Harkin Amendment of the Affordable Care Act. Per Section 2706(a) of the Patient Protection and Affordable Care Act, Public Law 111-148, health insurance companies, including Employee Retirement Income Security Act (ERISA) plans, cannot discriminate against and deny payment to any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.
Part of the issue with the way your medical plan is currently written to discriminate against optometrist may arise from a lack of understanding of the role doctors of optometry play in patients’ medical eye care. Medical eye care is part of every optometrist’s scope of practice in every state in the country as defined by the licensing board in their respective states. Of course, optometrists do provide routine vision care in prescribing and dispensing glasses and contacts, but in addition, optometrists are the primary care providers in this country for patients’ medical eye health. Optometrists in every state are licensed to detect, diagnose, treat, and manage diseases of the eye, as well as perform minor surgeries. Optometrists in most states are also licensed to prescribe ocular medications and have been assigned a DEA registration number by the US Drug Enforcement Administration to prescribe controlled substances. Optometrists are the gatekeepers to this country’s eye health, daily seeing patients to diagnose and treat medical eye diseases, with their early interventions often averting more chronic or long-term issues. When patients require treatment beyond the doctor’s scope of practice, optometrists refer them to the appropriate ophthalmological specialist for further assessment, treatment, and/or surgical management. Likewise, ophthalmologists regularly refer patients to optometrists for primary eye care once they’ve complete the specialized treatment the ophthalmologist has provided. Additionally, one recent study confirmed that general practice medical doctors refer patients in equal numbers to both optometrists and ophthalmologists when the medical eye condition is within optometrists’ scope of practice, e.g., diabetic patients at risk for diabetic retinopathy.
Likewise, every national insurance company in the country has optometrists on panel whom they reimburse for providing patients with medical eye care, including Medicare, Blue Cross, Aetna, United Healthcare, Cigna, and Humana. Frankly, if every insurance company wrote policies such as yours, there would not be enough ophthalmologists in the country to meet the primary eye care needs of every patient. As specialists and surgeons, ophthalmologists do not have the time nor inclination to monitor patients’ day-to-day medical eye health. Hence, ophthalmologists and optometrists enjoy a mutually beneficial referral system similar to general practice primary care physicians and specialists in other fields.
Refusing to pay optometrist for medical eye care not only violates federal law, but your policy is also egregiously out of touch. Policies such as yours where phased out after 1987 when Medicare classified optometrists as physicians with full parity to provide and receive reimbursements for medical eye care. By 2010 when the Affordable Care Act was passed, there were only a handful of throwback ERISA policies which still refused to pay optometrists for medical care. These policies were quickly updated to meet the intensions and mandates of the new law.
It is not in the best interests of your members to force them to change eye doctors or else bear the burden of the out-of-pocket expenses forced on them by your current policy when they choose to have their medical eye health care managed by an optometrist acting well within the doctor’s scope of practice. Therefore, we respectfully ask you to review and update your current policy to be in full compliance with federal law and reflect national norms and standards adhered to by all other payers.
Sincerely,
Optometric Billing Solutions
cc State Optometric Association
Disclaimer: We are not lawyers, and really these type of fights are usually better handled by state optometric associations who can bring their political clout to the table as well. However, we must all do our part in holding insurance payers and legislatures accountable. At OBS we have dedicated our professional careers to helping optometrists with the financial side of their practices, and we never pass up an opportunity to do our small part to fight for the profession wherever it comes under attack. We’ve actually had some past successes with helping educate other errant insurance plans and getting them to change their policies. We’ll keep you posted how this plays out!
