The Affordable Care Act and Optometry

OSU student Erica KellerBy Erica Keller, Ohio State University, AOSA Trustee-elect – Recently, Rick Cornett, Executive Director of the Ohio Optometric Association, came to speak at The Ohio State University College of Optometry about the Affordable Care Act (ACA)/Obamacare and how it will affect optometrists, both positively and negatively. More than 150 students came to listen, making it apparent that we have an interest in the future of our profession under the ACA. We want to know: What does this legislation mean for optometry’s future?

1. How will the increase in consumers with insurance benefit optometrists?
The increase in insured patients will allow more people to come to optometry offices and have coverage for services provided. Due to the legislative work of Sen. Tom Harkin (author of the Harkin amendment, which became part of the law), optometrists have been included in many health care plans and have not been discriminated against by major insurance providers who are looking to cut costs.*

2. The Harkin Law and Optometry
The Harkin Law provides patients easier accessibility to an optometrist of their choosing and prevents insurance carriers from keeping optometry services out of health care plans.* Unfortunately, this may not be the case forever. The introduction of the H.R. 2817 bill would undo the progress the Harkin Law has made in the advancements of gaining coverage under a health care plan and eliminating the need to have a stand-alone vision care plan.* Fortunately, optometry is a strong profession and the American Optometric Association is working hard to fight this newly introduced bill.

3. What can we do as students to ensure H.R. 2817 does not pass?
Donate to AOA-PAC through your school representative and, if you have the opportunity, go to Washington D.C. and lobby for optometry’s future. If this bill passes, it would allow insurance companies to implement plans that limit patient access to vision care by optometrists.

4. What is the future of pediatric vision care?
The ACA has implemented an essential health benefit (EHB) requirement that will include pediatric vision care as one of 10 essential benefits required in health care plans. This vision care benefit will be integrated into the plan as a whole and will allow children under 18 to have one comprehensive eye exam per year and material benefits.* Children who may have never had vision care insurance in the past will now be covered.

5. Medicaid Coverage Enhancements
Starting this year, Medicaid will extend its coverage to anyone with income under 133 percent of the federal poverty line.* This will allow citizens who are childless and without insurance to be covered when they would not have been eligible for government assistance previously.* It is up to each individual state whether they will accept this Medicaid expansion. The states that choose to participate will receive more money to manage the increase in Medicaid participants, but this does not mean that payments will increase for providers.* Contact your state association to find out what is being done and what you can do to help ensure fair payment to providers.

While the ACA has been a politically divisive issue, we must take measures to educate ourselves on its impact.
Students have a responsibility to ensure they are informed and proactive. Changes to health care in this nation are inevitable. We can choose to watch from the sidelines or make our message clear: we are part of the solution.

Erica Keller is a student at The Ohio State University School of Optometry and a trustee-elect for the American Optometry Student Association (AOSA). Her column appears in the Spring 2014 edition of Foresight, the AOSA magazine, and was reprinted with permission.

* “Top 5 ACA Changes for 2014: Are You Ready?” American Optometric Association, 8 Jan. 2014. Web. 02 Feb. 2014.

Online Eye Exams Troubling for Optometry

Dr. Elizabeth Muckley 2014By Elizabeth Muckley, OD, OOA Trustee – “The world’s first refractive online eye exam that delivers a valid prescription! Takes 5-10 minutes and costs 75% less than a traditional refraction exam!”

This is the advertisement for a Chicago-based online “eye exam” website that is supposed to go live this summer. The AOA has written a response published March 14 on

I encourage Ohio optometrists to pay close attention to this issue. This issue concerns patient safety, and affects each and every eye care professional in this country, regardless of practice mode or type. It is issues like these that remind us of the importance of membership in our professional organizations, OOA and AOA. Together we can advocate for our patients and demonstrate the value of our profession.

Membership in the AOA/OOA is an insurance policy you need just like for malpractice or your automobile. The AOA/OOA continues to develop strategies regarding online eye-testing sites and refracting kiosks in the interest of patient safety.

Read the article published in the Chicago Tribune March 12 about this issue:,0,0.story

May 7th Practice Management Institute Features Two Tracks

IMG_7958-2The annual OOA Practice Management Institute (PMI) – an excellent team-building event for doctors and staff – is May 7 at the Columbus State University Conference Center. This year’s PMI features four excellent speakers in two tracks:

Track 1
Practice management expert Laurie Guest will lead the workshop on the “Evolution of the Patient Experience.” In the morning session, Laurie will focus on the “Guest Encounter Audit,” which teaches participants to assess how their office processes patient inquiries to help eliminate bad practices. The afternoon session covers the “R-Formula Recipe” to attract and keep new patients. Laurie will also talk about the internal preparation for the impact of the affordable care act. This includes lean processing and improved communication between the doctor’s office and others.

Track 2
This track will cover several timely topics related to health care reform. In the morning session, Dr. Jay Henry, a nationally recognized speaker on electronic health records, will present on “Meaningful Use Stage 2.” Meaningful Use has changed the way ODs practice and how they will interact in the health care system of the future. Dr. Henry’s presentation will cover the requirements, clinical implications, exemptions, compliance and how to navigate Stage 2.

The afternoon session will start with Dr. Jason Miller, OOA Secretary/Treasurer, who will discuss the latest information and what doctors and staff need to know about ICD-10. Dr. Terri Gossard, OOA President-elect, will then share the most current updates on important legislation being debated in the Ohio Statehouse that could affect optometrists.

Registration, which includes a continental breakfast plus lunch, is $149 per doctor or for the first staff member if attending alone. Each additional staff member is $69. Fourth-year optometry students can attend PMI at no charge but must register.

Exhibitors will be available throughout the day, and include*:
Alcon Laboratories
Diversified Opthalmics
Essilor Labs
*As of March 12

You can register online at or download the registration form here. Registration deadline is April 25.

Practice Management Institute
May 7, 2014
Columbus State University Conference Center
315 Cleveland Avenue
Columbus, OH 43215

Registration: 8:30 a.m.
Morning Session: 9:30-11:30 a.m.
Lunch and Exhibitors: 11:30 a.m.
Afternoon Session: 1:30-3:30 p.m.

Coordination of Benefits – Why Make the Effort?

Miller 968Jason R. Miller, OD, MBA, FAAO – Please note: The following column is based on my experience and not an official opinion of the OOA. Every optometrist must decide how to handle this issue.

Are you confused about how to bill your diabetic patients? Especially your diabetic patients who also have VSP? Many health care payers have sent notices to many eye care providers asking for the claim when their member is diabetic. It’s kind of a blessing and a curse when two different carriers are asking for the claim with these specific patients. For example, this letter recently arrived in my office from Medical Mutual:

MedMut Form




These letters are correct when determining who to send the claims to, but need some clarification when it comes to actually submitting the claims and the order in which they are processed. There can be some confusion, as most vision insurances will not accept Refraction Only claims.

Determining who gets the bill starts with the reason for the visit. The patient’s reason for the visit should determine who gets the bill. If it is a refractive complaint (Myopia, Presbyopia, etc.), the vision plan should receive the bill for the encounter. If is a medical complaint (Diabetes, Dry eyes, Allergic Conjunctivitis, etc.), the medical insurance should get the bill for the encounter. That reason for the visit can be either a patient complaint or an order from the doctor at their previous visit (for example: Order Procedure: Glaucoma Work-Up in three months). That order from their previous encounter becomes the reason for the visit when they come in for that testing.

Typical Scenario:

If the patient is diabetic, they may be in for new glasses or contact lenses and their annual diabetic exam as prescribed by their primary care physician or endocrinologist. One possibility is to provide their vision exam (submit to vision) and have them back for any diabetic testing (submit to medical). That is typically not very patient-centric, as we can usually provide this service at the same time and will save the patient a trip to our office. This article details steps to take in order to coordinate the patient’s visit between both their Medical and VSP when appropriate.

  1. To coordinate this claim to VSP, there must be a refraction done on the same date as well.
  2. The exam can be either a 99xxx or 92xxx CPT, whichever you deem appropriate. The medical exam needs to be pointed to the medical diagnosis (choose a Diabetic code in this scenario – 250.xx) listed in position 1 on the HCFA form.
  3. The refraction (92015) must be pointed toward a refractive diagnosis.
  4. The claim, in its entirety with the exam, refraction and any special testing if applicable (92250 Fundus photos if medically necessary), will be filed to the health insurance carrier for consideration.

Note: You do not have to collect any co-pays at this visit.

The health insurance is going to process the claim as primary and they are going to pay based on the patient’s coverage for that service. Once the health insurance processes the claim, you will receive the explanation of payment (EOP). After the health insurance company processes the claim as primary, the claim can then be filed to VSP under their coordination policy.

Keep in mind that this secondary claim to VSP must mirror the primary claim exactly. This is not just sending the refraction code to VSP. The CPT codes and diagnosis order cannot be altered.

Once VSP gets the secondary claim, they will pay up to $66 on Signature or Choice plans, less the copay amount per the patient’s plan. VSP will not pay on any testing overages the primary does not cover. They will only pay on the exam and refraction overages that the health insurance carrier does not pay.

COB Max COB Payment for all states as of 04/01/13:






Let’s say they have a $30 copay from the medical insurance and the $XX refraction is non-covered. Per the health plan, the patient’s total out of pocket should be $30 + $XX for the refraction.

Next steps – this is taken directly from the VSP Coordination Policy (click on the link for the policy):

For Paper Claims:

  • When you receive payment from the health plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

For Electronic Claims:

  • When you receive payment from the health plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

After the claim is submitted to VSP as secondary and when VSP considers the claim, they are willing to pay up to $66 ($66 less the $XX VSP copay) as secondary. Of the $30 + $XX balance that is outstanding from primary, VSP will cover their portion and the patient responsibility will be what is left, if anything.

Please Note: There is no VSP write-off when VSP is acting as secondary. The primary health insurance allowable will be honored, but VSP requires no additional write-off on a medical coordination; it is a flat benefit amount as secondary.

Explaining this to the patient can also be a challenging situation, but Dr. Neil Gailmard just had a very good practice management explanation of this situation along with a handout to use with patients. I have copied and pasted this explanation from his post, but you can also access this online at:

Optometric Management Tip # 561 – Wednesday, December 05, 2012

A Patient Handout for Vision vs. Medical. In last week’s article, I provided an overview of the differences between vision plans and medical insurance. If your practice routinely bills all eye exams to vision plans, you may want to consider differentiating medical eye exams from routine vision exams and billing the former to medical insurance plans. 

The difficult part of this process is educating patients about the differences. That requires significant staff training, but a patient handout like the one below can be a big help. Feel free to modify the form below to describe your office policies. The handout can be given to patients at check-in or check-out and it serves as a guide for staff members as they speak to patients over the phone. I find it is best to keep educational handouts short and simple. Many patients simply will not read a form if it is long and wordy.

***Sample Handout***

About Your Insurance. There are two types of health insurance that will help pay for your eye care services and products. You may have both and our practice accepts both: 
Vision care plans (such as VSP and EyeMed)
Medical insurance (such as Blue Cross/Blue Shield and Medicare).

Vision care plans only cover routine vision exams along with eyeglasses and contact lenses. Vision plans only cover a basic screening for eye disease. They do not cover diagnosis, management or treatment of eye diseases.

Medical insurance must be used if you have any eye health problem or systemic health problem that has ocular complications. Your doctor will determine if these conditions apply to you, but some are determined by your case history.

If you have both types of insurance plans it may be necessary for us to bill some services to one plan and other services to the other. We will use coordination of benefits to do this properly and to minimize your out-of-pocket expense.

We will bill your insurance plan for services if we are a participating provider for that plan. We will try to obtain advanced authorization of your insurance benefits so we can tell you what is covered. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays or non-covered services as allowed by the insurance contract.

I have read and agree with these policies.

________________________            __________

Patient signature (parent if child)                Date

Please provide your insurance cards to our staff member.

Best wishes for continued success,

Dr. xxx, O.D.

A special thanks to my business partner, Dr. Tamara Kuhlmann, OD, MS, FAAO, and Branda Barton of Optometric Billing Solutions for their assistance with this article.

Managing Mandatory Children’s Eye Exams

Dr Jeff MyersBy Jeffrey Myers, OD – I love kids. Spending time with my two grandchildren always brings joy and is a highlight of my day or week. At reunions of my wife’s family, I rarely am talking to the adults. More interesting to me is connecting with the folks under 18. Many of my volunteer activities over the years have been focused on young people. I find that connecting with the young folks at church when volunteering with the youth group is energizing. Generally, young folks enjoy the attention of an adult who is truly interested in talking to them, and who treats them as an equal.

In practice, you might share the experience with me that certain types of patients are energizing, interesting, and intellectually stimulating. For me, removing foreign bodies, relieving the pain of iritis, and protecting patients from the loss of vision associated with glaucoma all fall into this category. I confess that examining patients under age 10 does not fall into this category. While I love kids, my passion is not in examining them. And examining more than one child a day is draining for me. So, what do you do if you share this challenge of examining young children with the implementation of the pediatric Essential Health Benefit under the Affordable Care Act (ACA) which has mandated eye exams for children?

Fortunately, I observed this about myself more than a decade ago. As I was looking to add a second doctor to our practice, I specifically looked for a doctor who brought a passion for pediatrics to the practice as well as an interest in cultivating a vision therapy practice. Dr. Amy Keller fit that profile and joined my practice in 2005. Her lack of interest in managing glaucoma patients made our skill sets complementary. In addition her special interest in the challenging contact lens fit and dry eye round out a valuable doctor.

In 2011, we were finding our schedule busier and needed additional doctor coverage. Dr. Kari Cardiff joined our practice and shares Dr. Keller’s passion for the young folks. She had experience in performing vision therapy and brought an additional passion for vision rehabilitation. Her addition has allowed the expansion of specialty services in the practice, adding greater value for our patients.

Today, patients who come to our practice are matched with a doctor passionate about meeting their vision care needs. Young folks see Dr. Keller or Dr. Cardiff, glaucoma patients usually see me, and patients in need of special services are connected with the doctor best suited for them. Other professionals build practices centered around the strengths and interests of the individual doctors. We can learn from that model.

If seeing young patients is not your interest yet you anticipate an increase in pediatric patients, consider the addition of a colleague who has a passion for the young patients. Your patients deserve someone who is excited about caring for them.