The Business of Contact Lenses

Begin Again at the Beginning

BY CLARKE D. NEWMAN, OD, FAAO

I recently presented a webinar for the Gas Permeable Lens Institute (GPLI) on billing and coding for medically necessary contact lenses, and learned that it was by far the most attended session the GPLI has ever held. Clearly, there is a thirst for knowledge in this arena.

When I first started writing for Contact Lens Spectrum in 2008 (Has it really been five years?), I started by walking everyone step-by-step through the process of coding and billing for medically necessary contact lenses. Each month, I covered more of the process. A great deal has changed over the intervening years, so perhaps it’s time to start fresh.

Here Goes…

First, there are consumers of health care—our patients. Second are providers of healthcare services—doctors and other healthcare workers who manage the treatment for contact lens consumers. Third are purchasers of health care. These may include patients who buy individual health plans, employers who purchase group health plans, state or local governments, or the federal government. Finally, there are payors of healthcare services, who may be individuals paying out of pocket, employers who have self-insured programs through ERISA, indemnity companies such as Blue Cross/Blue Shield that sell health insurance products to purchasers, or governmental entities at the county, state, and federal levels.

The relationship between these various actors is contractual. Within the framework of the various program contracts are rules and product limitations for the private markets, and laws and regulations for the public markets. These rules, laws, and regulations, combined with some commonly shared terminology, such as the American Medical Association’s Current Procedural Terminology (CPT), control all of the players in the healthcare marketplace.

Insurance 101

If you want to understand how to navigate the healthcare marketplace, then you must learn the rules, laws, and regulations that control that market.

In our current system, healthy people have very few healthcare costs. When a consumer has health problems, the cost of health care can be more than what most consumers can bear. Consequently, they hedge that risk by purchasing some type of indemnity protection from a pay-or, or “health insurance.” People who cannot afford insurance, either individually or through an employer, receive assistance from a governmental entity. It is not a good system, but it is the one under which we all currently live.

You Should…

It makes sense for providers to contract with payors whose products offer reimbursements that make economic sense. Part of our obligation is to acquire the expertise and provide the wherewithal to deliver these specialty services to all patients including those in need. The other part of that obligation is ensuring that we can keep the lights on and our doors open. That means we have to receive in compensation for our services payments commensurate with the level of expertise and risk involved in delivering those services. If a contract presented to you by a payor does not provide such levels of compensation, then do not contract with that payor.

Finally, everything that the so-called “experts,” including me, say doesn’t matter. The answer to every question, with very few exceptions, is contained in the rules, laws, and regulations that govern what we do. It’s all there for you to discover and, more importantly, to understand. CLS

Dr. Newman has been in private practice in Dallas, Texas since 1986 specializing in vision rehabilitation through contact lenses as well as corneal disease management, optometric medicine, and refractive surgery. He is a Diplomate in the AAO and a consultant to B+L and AMO. Contact him at cdnewman@earthlink.net.