RGP insights
Managing Specialty Contact Lenses Under Managed Care
BY LORETTA B. SZCZOTKA, OD, MS, FAAO

Fitting gas permeable contact lenses to a diseased, injured or surgically altered eye is the easy part. Billing and getting paid for the expert skill and quality product you provide is often the hard part, especially in a managed care environment.

This is a significant concern for the relatively small number of us who fit the majority of patients requiring medically necessary contact lenses for visual rehabilitation. We have spent years learning the art and science of fitting irregular corneas. We may spend weeks or months perfecting a specialty lens fit. Yet most insurance plans do not compensate us adequately for our time, and in many cases force us to take a net loss on our lens costs.

Take, for example, an insurer that agrees to pay for medically indicated contact lenses. The insurer usually pays the standard reimbursement for contact lenses in the industry, which typically covers only the costs of a simple spherical lens. Most contracted plans do not allow you to balance bill for your usual fee. By the time you order a warranted lens, exchange, reorder and possibly exchange the lens again, your costs for a spherical lens break even. Many diseased cornea patients require a specialty design, and the costs of these lenses far exceed what the managed contract is willing to pay.

Why belong to plans which reimburse so poorly that we lose money on every patient we see? In my hospital-based setting, I cannot feasibly avoid these plans because they encompass the large national or regional carriers that have contracted with the hospital. Other practitioners may join for access to panel provider status for medical eye care. Ironically, the plans do not recognize the complexities and fees associated with medically indicated lenses. It is not uncommon for base costs of keratoconus, semi-scleral and other specialty designs to exceed the high end of managed care reimbursements, and practitioners can lose thousands annually.

Why not look for plans that view contact lens fittings (procedure code 92310) as non-covered services, allowing you to bill the patient in full? This is more lucrative for the practice but penalizes the patient. Groups such as the National Keratoconus Foundation frequently lobby for keratoconus contact lens reimbursements. I applaud the NKCF for their efforts, but I also plead for fair reimbursements to the provider so insurance does not begin to dictate how we practice.

Expertise Pays Off

If low reimbursement rates are expected, learn how to fit, modify and design GPs well to lower expenses. I custom design GP lenses whenever possible without relying on higher priced proprietary fitting sets. Although many of these designs work well, a good GP fitter can work with his lab to create a unique corneal lens for each patient for up to one third the cost (except scleral lenses, which demand specific and precise fitting sets).

If given the option, always fit GP rather than soft. For example, in aphakic contact lens fittings (92311), which are a covered service on most plans, expect a net loss if you provide a soft lens for these patients. Instead, opt for GP lenses which provide better oxygen transmissibility and optics and are more reasonably priced for the reimbursement expected.

For some specialty fitters, it may be feasible to stay out of most managed care plans. Others may worry that their exam chair will remain empty if they don't sign up with a large plan. Specialty GP fitters are the last chance some patients have for visual rehabilitation. If this is your passion, patients will find you, and are usually willing to afford your services. I welcome any comments from fellow readers.

Dr. Szczotka is an associate professor at Case Western Reserve University Dept. of Ophthalmology and Director of the Contact Lens Service at University Hospitals of Cleveland.