Financial

Does Vision or Medical Insurance Cover Myopia Management?

November 1, 2020

By Alan Glazier, OD, FAAO

Our practices thrive with specialty eye care. Optometry specialties create additional revenue streams and help us stand out from the competition. Specialty eye care often requires a higher level of knowledge, training and equipment than standard care, so additional investment in education, time and equipment is often needed. Parents seeking specialty eye care for their children value that care at a higher level. We must effectively communicate the additional value we provide when parents of myopic children present with vision plans or medical insurance.

Let’s use the three most common evidence-based myopia management methods to demonstrate our office’s pricing structure with vision and medical plans. Those methods include orthokeratology, distance-center multifocal soft lenses (MiSight 1 day, lenses included) and topical low-dose atropine.

VSP and EyeMed generally offer two plans: (1) CL exam allowance and materials allowance and (2) a CL copay in addition to material allowance. These discounts are then applied to the myopia management fees. Fees can be structured as “bundled” (aka “global”) or “unbundled.” Bundled fees include services and lens costs as one fee. Unbundled fees break down the service and product costs separately. Bundled fees create challenges in bookkeeping, specifically in determining cost of goods, which is vital to keep a handle on, as knowing the cost of goods helps manage expenses. We prefer to have our OrthoK fees unbundled for this reason.

  • OrthoK: If the patient presents with a vision plan, we take the total discount (services and materials or copay and materials) and apply it to the materials fees. If the patient presents with a medical plan, we perform the comprehensive eye exam under the medical plan and discuss OrthoK and the non-covered fees for therapy and materials. Patients presenting with medical insurance with no vision plan are told they are responsible for fees associated with OrthoK services and products that are non-covered. To soften the blow, we let them know if they have medical-flexible benefits, we will provide a receipt so they can submit and potentially be reimbursed.

When a patient decides to undergo treatment with OrthoK, we proceed as we would with specialty-lens therapy. First, we never refer to the OrthoK molds as “contact lenses.” They are “molds,” “medical devices” or “therapeutic lenses” to differentiate this from standard contact lens services in terms of value in the minds of the parent.

  • Multifocal soft lenses: When a patient undergoes treatment with multifocal soft contact lenses, such as MiSight 1 day, we utilize unbundled fees and apply the vision plan discount in the same manner as OrthoK. With multifocal soft lenses it is important to refer to lenses as something other than contact lenses. I like to call them “medical devices” to bolster the perception they are both corrective lenses and slow the progression of myopia. This is especially important with soft lens options for myopia management. They come in six-packs that have the perception they are standard spherical contact lenses, leading parents to question the higher specialty fees you are charging. If the patient presents with a medical plan, we perform the comprehensive eye exam and discuss non-covered myopia management services and associated material fees. Patients presenting with medical insurance are responsible for overage fees associated with myopia management professional services and products. We let them know that we will provide a receipt if they have medical-flexible benefits so they can submit and potentially be reimbursed.
  • Atropine: When a patient presents with a vision plan and undergoes myopia management with topical low-dose atropine, there are no material benefits that can be applied. The atropine must be compounded at a compounding pharmacy, and they receive payment for the drops directly from the patient. The doctor’s responsibility is to provide the vision exam as contracted by the vision plan or medical plan and explain to the patient there will be charges for follow-up visits to manage myopia progression. We provide quarterly visits to refract and measure axial length and charge the patient accordingly with an office visit fee. While some medical insurance companies may pay for myopia management visits, I am unaware of any acceptable coding when this article was written.

When talking to parents, it is crucial to never refer to vision plans as “insurance.” Instead, refer to them as “discount” plans. This wording is critical for setting expectations that they do not have comprehensive coverage for the specialty service, only a discount. There will be a balance they are responsible for.  Ensure the verbiage “discount plan” is repeated at all contact points in your office, such as customer care/front desk, technicians and doctors.

Not all eye care professionals offer specialty services such as myopia management, and it will be difficult for the parent to find these services elsewhere. Also, you have made a financial and educational investment in yourself and your practice by implementing a specialty. You have elevated yourself as an expert, and your practice stands out as a result. Discounting, other than with vision insurance “discount plans,” cheapens your image and can result in the “slippery slope” of decreasing pricing like what happened with LASIK and the “race to the bottom.”

 

 

 

Alan Glazier, OD, FAAO, is the founder of  Shady Grove Eye & Vision Care based in Rockville, Maryland, and the founder and visionary behind ODs on Facebook and ODsOnFB.com.

 

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