The Business of Contact Lenses

VSP and EyeMed, Again: A Few Things Have Changed

BY CLARKE D. NEWMAN, OD, FAAO

I have been critical of the vision care plans (VCPs) over the past several years for some of the things they have done. However, if my VCP criticism is to be taken seriously, I must be willing to give credit where it is due.

During 2015, representatives from both VSP Global and EyeMed Vision Care sat down with either myself or Dr. Stephen Montaquila, chair of the American Optometric Association’s Third Party Center, to address our concerns regarding medically necessary contact lenses (MNCLs).

What Changes Were Made

First, EyeMed clarified a problem that was unintentionally created while trying give a better reimbursement for keratoconus. At first, the change made it seem as though anything but severe keratoconus was a non-covered service. When we sat down, Eye-Med was genuinely flummoxed at the confusion, as that was not the intent at all.

As we met, we realized that a simple change in the Authorization Form would clear up the confusion and properly convey that the benefit was actually expanding. So, familiarize yourself with the new form, and act accordingly. The newer form also addresses ICD-10-CM. EyeMed purposely did not define too narrowly the dividing line between the two categories, as the intent was to leave that mostly to the discretion of the provider.

Several changes were also made by VSP. First, the term of service was defined as a 90-day period; after that, the provider is expressly allowed to bill the patient’s medical carrier. This change allows practitioners to do what we need to, and it avoids the silly predicament of having providers guess, in advance, the number of visits it would take to complete the service. This guessing game was leading to significant recoupments at audit if practitioners guessed incorrectly.

Next, and quite significantly, was the addition of aniridia and other pupillary defects, as well as albinism, to the covered services data set. There are many afflicted patients who will benefit from this change in coverage. EyeMed covers these conditions, but only for pediatric patients in certain plans in California.

Another change was an acknowledgment of the significant asymmetry between reward and punishment in the system that VSP was using at audit. The recovery will now be limited to extrapolations on necessary contact lens billings, not on all billings to VSP. That policy change is substantially fairer; also, it better represents the fluid nature of MNCL prescribing in that it is difficult to predict what will be needed and that missing the mark is typically not an indication of fraudulent intent.

Other Policy Items

While not changes, it is important to note some of VSP’s policies. First, keratometry and topography must be performed to substantiate a diagnosis of keratoconus. Second, high ametropias and anisometropias are based on the spectacle prescription, which must be provided. Third, box 19 must contain the word “scleral” in addition to the manufacturer and lens design for scleral reimbursement, and hybrids are expressly not scleral lenses under the VSP policy. Finally, there are piggyback and over-spectacle benefits available under the VSP Visually Necessary Policy.

So, take the time to read up on those respective changes, which will allow us all to be better served. CLS

Dr. Newman has been in private practice in Dallas 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 or advisor to Alcon, Allergan, AMO, B+L, EyePrintPro, GPLI, Johnson & Johnson Vision Care, SynergEyes, TruForm Optics, and Zeiss Optics. Contact him at cdnewman@earthlink.net.