The Conundrum of Medically Necessary Contact Lens Reimbursement

As I continue to read about advances in specialty contact lenses and to participate in their rollout, I have been asking myself what is to be done about the issues associated with getting reimbursed for medically necessary contact lenses. The innovation, technology, and cost associated with delivery of these lenses continue to move at a rapid pace; in contrast, the insurance reimbursement response to help the patients who need it the most has remained seemingly static. Practitioners are at the mercy of their insurance contracts at times when certain contact lens options may exceed plan reimbursement.

The Health Policy Institute of the American Optometric Association surveyed more than 800 doctors of optometry in June 2020 about vision plan fee schedules. The results indicated that “70% of doctors reported not receiving an increase in the fee schedule for their largest vision plan in at least five years, and, thinking back to that last increase, 69% of doctors reported that it had been at least six years or more since the previous increase,” (www.aoa.org/AOA/Documents/Advocacy/HPI/HPI_Stagnation_in_Vision_Plan_Fee_Schedules.pdf ).

Time marches on, and costs continue to rise as they relate to keeping practices open so that practitioners can continue to offer care to patients despite static reimbursements for eyecare services that have high clinical value. The costs associated with individual practice protocol changes during the COVID-19 pandemic are just one example among many.

I want to pose some questions to this readership, which includes a specific group of eyecare professionals who are interested in delivering specialty contact lens services to their patients:

1. Are reimbursements for true medically necessary contact lenses falling behind—or are they non-existent—with regard to practitioner costs associated with new advances in contact lenses in all of their varieties (i.e., advanced-design GP lenses [free form, wavefront], myopia control, etc.)?
2. Are certain plan criteria for medically necessary lenses following outdated classifications and standards of care (e.g., keratoconus classification as well as failure to recognize both myopia as a disease process and vision disturbance related to higher-order aberrations)?
3. What is our role as eyecare professionals and as specialty lens fitters with respect to informing the companies of large insurance plans to get with the times and to modernize their policies? If my experience is any indication, writing letters of medical necessity is often both time consuming and ineffective.

Little seems to be changing in the realm of insurance reimbursements for our critical vision services; at the same time, the contact lens options that we can provide to patients continue to expand and to improve at record pace. Patients pay for insurance to ensure that they have access to quality care without undue financial hardship. When insurance companies fail to recognize advances in medically necessary contact lens options, it punishes both the patients who are not able to access these advanced technologies and the providers who should be compensated for their required expertise and proficiency.

We have a dual advocacy role to provide necessary services to our patients and to also be fairly compensated for the services that we provide. Past experience shows that any efforts up to now have resulted in little to no change in policy or reimbursement.

Perhaps we, as individual eye-care practitioners, need to contact the leadership of individual vision plans to get the ball rolling on changing this situation rather than wait for large-scale advocacy efforts? Any other ideas?

—Brayden Lundquist, OD, West Valley Vision Center, Goodyear, AZ. Dr. Lundquist has received remuneration from Ovitz Corporation.