Medicare Advantage Plans/Medicaid Managed Care

by Mark Ridenour, OOA Consultant

Medicare Advantage Plans

Medicare Advantage (MA) plans are growing in popularity (from 26% of Ohio Medicare eligibles in 2008 to 36% in 2012), and if you are a participating provider you have become even more valuable to MA plans. Medicare pays private insurance companies a capitated amount to provide hospitalization, professional, and prescription drug benefits as MA products to those eligible for Medicare. This is an alternative for beneficiaries to taking traditional Medicare benefits from the federal government.

MA plans are approved for sales to beneficiaries by county. There are now 28 plans available in Ohio with 8 of those being Special Needs Plans (SNPs), specifically those in long-term institutions or dually eligible for both Medicaid and Medicare. MA payers include large insurers like United HealthCare, Anthem, Aetna, Kaiser and Humana and many local or regional carriers such as SummaCare, MediGold, and CareSource.

The Affordable Care Act (ACA) has modified the plan payment formulas to reward quality measures. Performance on these are represented by a 5 Star system which was originally designed to help consumers choose high quality plans, but now carries the greater weight of increased funding and more liberal enrollment parameters for the insurers. Of the current 37 metrics used to rate all MA plans, Glaucoma Testing and Diabetic Eye Exam are included. In addition, #22 is Fall Prevention where a vision exam is recommended, and others measure customer satisfaction (e.g., Getting Appointments and Care Quickly) which could include members’ perception of their Optometrist. This focus on quality Stars should increase your leverage with the plans and lead to outcome-based bonus payment and/or increased volumes to your practice.

If you find your practice is excluded from a Medicare Advantage product and the plan seems unwilling or unable to add you to their network, please take the following steps:

1. Contact the ophthalmologist(s) you generally refer patients in this MA plan to solicit their support for continuing to receive referrals.

2. Encourage your patient to contact the MA plan as a member to your practice be added.

3. Inform OOA.

Medicaid Managed Care

The Medicaid Managed Care Plans for all regions of Ohio starting July 1, 2013 are:





United HealthCare

InfantSEE: A Tenth

By Dr. Bill Lay, Chair, Ohio InfantSEE

InfantSEE Banner2One tenth. 10%. It may not seem like a lot. Ohio volunteer doctors do one tenth of all the InfantSEE exams reported in the United States. In 2012, Ohio doctors reported 1,095 InfantSEE exams; a total of 11,451 InfantSEE exams were reported in the country. Throughout the eight-year history of InfantSEE, 97,267 InfantSEE exams were reported by Ohio ODs throughout America. Ohio ODs reported 9,520 InfantSEE exams, I assume Ohio will go over the 10,000 mark for InfantSEE exams in 2013; I also assume the 100,000 mark will be eclipsed in the United States.

Thank you, InfantSEE volunteers. We can do more – educate more parents, inform more relevant parties like nurse practitioners and pre-school teachers, examine more babies. In our practice – Professional Vision Care of Westerville and Johnstown – we do the following:

  • Host free seminars for moms to educate them about the importance of baby vision exams.
  • Tell mother for father in the exam chair who are expecting or recently had a baby about InfantSEE – they are often amazed that we can even examine an infant.
  • Give baby packets to new or expecting parents that include information about stages of vision development, information about infant exams, tips for parents on things they can do.

Be proactive in recruiting within your own patient base. You will expand your clinical skills and fill your exam slots with excitement.

ODs and E-Prescribing

ODs are exempt from the payment adjustment scheduled to take place in 2014 for E-Prescribing.

If optometrists e-prescribe for Medicare patients with an office visit 25 times during the year, they can receive a 0.5% e-prescribing incentive bonus on all allowable Medicare charges for the year. They  must report code G8553 on Medicare claims with an office visit to get credit. ODs can get the e-prescribing incentive bonus and the PQRS bonus and the Medicaid EHR incentive. The only two ODs cannot do together are e-prescribing incentive and Medicare EHR incentive.

All ODs are encouraged to begin e-prescribing, if they are not already doing so. It is a core requirement of stage 1 and stage 2 meaningful use.

For ODs not ready for meaningful use, e-prescribing is a great way to start using computers for patient care.

For ODs who have an EHR, talk to the vendor and utilize the integrated e-prescribing.

For ODs who do not have an EHR, visit NEPSI which has free e-prescribing for every physician in America.

Top 10 Reasons to Attend EastWest Eye Conference

EW Logo2010

Top 10 Reasons to Attend EastWest Eye Conference

October 3-6, 2013 – Downtown Cleveland, Ohio

1. Support Optometry: all proceeds go back to the profession

2. Hear the nation’s top optometry speakers

3. Attend OD Tracks including Disease, Glaucoma, Contact Lenses, Neuro-optometric Rehabilitation, Low Vision, Binocular/Pediatrics, Vision Therapy and more

4. Party the night away at the Friday night event at the Rock and Roll Hall of Fame

5. Meet industry experts and optometry’s friends in the Exhibit Hall

6. Network with colleagues

7. Experience the newly constructed state-of-the-art facility on the shores of Lake Erie

8. Join in the fun at sponsored breakfast and lunch events

9. Bring your entire office to attend courses for Allied Eye Professionals with ABO, NCLE, JCAHPO, CPC approval

10. Celebrate with Ohio Optometric Association at their annual meeting

Register Now!

EHR Use Required to Avoid Medicare Penalties in 2015

Medicare-eligible professionals who do not demonstrate meaningful use under the Medicare Electronic Health Record (EHR) Incentive Program may be subject to payment adjustments beginning on January 1, 2015, according to the U.S. Centers for Medicare & Medicaid Services (CMS). Practitioners who first demonstrated meaningful use in 2011 or 2012 must demonstrate meaningful use for a full year in 2103 to avoid payment adjustments in 2015. Those who first demonstrate meaningful use in 2013 must demonstrate meaningful use for a 90-day period in 2013 to avoid payment adjustments in 2015. Those who first demonstrate meaningful use in 2104 must demonstrate meaningful use for a 90-day reporting period during the first nine months of that year to avoid payment adjustments in 2105.

For additional information see the AOA EHR page and the AOAExcel EHR page.

More on ACOs and How OOA/AOA is Helping

The AOA has made the elimination of barriers to OD participation in Accountable Care Organizations (ACOs) a top priority. The result has been important gains for the profession that are reflected in the regulation implementing the new health care law and new opportunities being explored by optometrists related to value-based care models and pioneering partnerships with other providers.

As was first reported in the May 24 AOA First Look, a volunteer workgroup coordinated by the AOA’s Third Party Center is now working to develop a resource toolkit and practical guide for optometrists who are interested in exploring ACO participation. The workgroup is nearing completion of its product – a toolkit of education materials and other resources that detail what optometrists need to know and what to do when engaging with ACOs. The first article, entitled “What Optometrists Need to Know about ACOs”, can be found here. The workgroup’s latest installment, “What Optometrists Need to Do about ACOs”, can be found here. The AOA’s overarching goal is to help its member optometrists gain full access to these new ACOs and other value-based care delivery models.

To be sure, current national health policy and major sections of the Affordable Care Act support a shift toward integrated, coordinated, and accountable care. Many ACOs have already been formed and are operational, and many more are currently being formed. Market penetration of ACO coverage is expected to increase considerably over the next few years. Right now, approximately 250 ACOs are accountable for the cost and quality of care for more than four million Medicare beneficiaries (roughly 10 percent), with more Medicare ACOs expected to come online next year. Additionally, more than 400 ACOs are ACO-like private entities that are engaged in value-based contacting activities with commercial insurers and large employer-based health plans are thought to be involved in thousands of private contractual arrangements covering more than 30 million Americans, or approximately ten percent of the U.S. population.

Ultimately, gaining ACO inclusion in most cases will be up to the local optometrist. For its part, though, the AOA will continue to advocate for ODs to be included in these and other value-based care models in a way that allows ODs to practice at the full scope of their license. At the same time, the AOA will keep its focus on the integration of eye health and vision care in all health plans that work with ACO-like entities in value-based insurance arrangements, and will continue working to make organizations, groups and associations involved in ACO developments and management aware of OD interest and the potential role of ODs in ACOs, ensuring that those organizations turn to the AOA and state affiliates for help with attempting to involve ODs. Meanwhile, AOA’s wholly-owned subsidiary, AOA Excel will continue implementing a plan to provide related information technology and connectivity tool that will support various models of OD integration into ACOs.

Look for more articles on this important topic leading up to Optometry’s Meeting. Questions about the ACO workgroup and the coming ACO Toolkit for Optometrists should be directed to

Realeyes in Brown County

IMG_2181Realeyes presented all four curricula – Sammy Safe-Eyes, Rhet & Tina, Vinny Vision, and What Your EYE-Q – to over 400 students at Fayetteville-Perry Local Schools (Brown County) May 28.

Kindergarten students played games and sang songs during Sammy Safe-Eyes. Puppets Rhet and Tina starred in the presentation to 1st and 2nd grade students. Optical illusions were used to solve a mystery about Vinny Vision for 3rd and 4th grade students. The 6th grade students participated in lab activities during What’s Your EYE-Q.

Zelda Weaver Searls, program coordinator for Ohio Department of Health Save Our Sight which funds Realeyes, was a special guest.

Please contact the OOA to schedule a presentation.

Professional Unity

by Rick Cornett, Executive Director

What a phenomenal journey it has been serving the optometric profession the past 16 years. Reflecting on the 43 years I’ve spent in healthcare, the privilege of being a spokesperson for optometry and primary care is a highlight. Certain aspects of my tenure as your executive director stand out. Most experiences have been positive but, as in human nature, the negative ones seem to demand the most energy.

One unexpected and unnecessary problem for organized optometry is the lack of professional unity. The optometric family has much to be united over, starting with making each patient as good as they can be visually. But numerous other issues continually distract from this basic core mission. You can fill in the blank as to those distracting issues. Our focus should always be “the profession to be emulated.”

An historical example of unity comes to mind. in The Sound of Laughter by Bernard Cerf he relates a story about an event Ed Sullivan staged for returning WWII wounded veterans which took place at Halloran General Hospital on Staten Island. Comedian Jimmy Durante who was popular with the GIs agreed to do a short song even though he had a bad cold and had another commitment. The veterans were eager for the show. Durante did his number and was greeted with thunderous applause. He returned to the stage for an encore with additional songs, and the event was said to be the greatest entertainment night for wounded veterans. Sullivan later asked Durante why he had stayed when he had other pressing commitments. Durante said he looked through the stage curtains and two young lieutenants in the center front row who had each lost an arm and were applauding their two remaining hands together. “When I saw that, Ed, I made up my mind that my next commitment wasn’t as important, and my cold wasn’t important either.”

Unity. Working together. Common goals. For optometry it seems to this executive director that the goal is to make sure each patient can see as good as possible. That takes commitment from the patient, the primary eye care doctor, those of us who work for you including your professional organizations, and any other groups that agree with this simple philosophy. Let’s focus on professional unity that is patient – and optometry – centered. Although the concept may be simple, too many other agendas seem to get in the way. Let’s eliminate the distractions and move on with a common agenda of “unity” at a time when it is needed more than ever.

Dr. Earley is AOA Educator of the year

Earley PhotoOOA Trustee Michael Earley, OD, PhD, has been awarded the 2013 American Optometric Association Educator of the Year. He is the Assistant Dean for Clinical Services at The Ohio State University College of Optometry.

Dr. Earley is a 1988 graduate of The Ohio State University College of Optometry. During his graduate studies, he was twice awarded an Ezell Fellowship from the American Optometric Foundation and the Auxiliary Fellowship from the American Optometric Association. He received his PhD in Physiological Optics from The Ohio State University in 1992.

Many graduates of the Ohio State University College of Optometry consider Dr. Earley the best teacher in their entire academic career. His encyclopedic knowledge of anatomy, neurology and pediatrics is remarkable; in fact, many students secretly lament that Dr. Earley doesn’t forget anything. But what makes him unique is his ability to communicate information that is, at times, dry, detailed, and abstract in an energetic, humorous, and memorable way. This rare combination of uncanny intelligence and clever wit is recognized and appreciated by his students, as seen in their Facebook pages dedicated to his more memorable quotations and their election of Dr. Earley to the Ohio State University’s highest teaching award, The Alumni Award for Distinguished Teaching. This award is granted as a result of student and alumni voting, which makes the honoring Dr. Earley even more special as the College of Optometry is roughly 1/250 the size of the overall university enrollment.

In addition to being an educator of future optometrists, Dr. Earley is also a valuable educator outside of the college. He has been the key speaker for the OOA at multiple Ohio School Nurse Symposia since 2004, presenting information to school nurses concerning ocular anatomy, eye health, and eye safety in his charismatic way. On behalf of the AOA, Dr. Earley was a keynote speaker at the 2011 AOA School Readiness Summit: Focus on Vision in Alexandria, Virginia which included a national group of educators, health care professionals, and policy makers.

Clinically, Dr. Earley primarily works with children with special needs and patients with traumatic brain injury. He is the recipient of numerous awards in his career including OSU’s highest teaching award, the Alumni Award for Distinguished Teaching, and was inducted into the Ohio State University Academy of Teaching. He has authored more than 80 abstracts, book reviews, publications and has lectured nationally at more than 50 venues.

His is president and coordinator for Optometric Educators, Inc. He serves on the Association for Schools and Colleges of Optometry’s clinic directors’ special interest group. Dr. Earley is a member of the Association for Research in Vision and Ophthalmology and the American Academy of Optometry.

He and his wife, Tracy, reside in Powell; they have three children.