The AOA Third Party Center advocates for the inclusion of full-scope optometric care and the inclusion of comprehensive ophthalmic examinations as a core benefit in all medical insurance and ERISA plans so that all Americans have access to quality eye care through their choice of appropriate provider.
The Third Party Center (TPC), comprised of AOA staff and volunteer doctors of optometry, is charged with the following:
- To ADVOCATE for the inclusion of optometrists in all medical eye care whether provided privately, publicly or through any third party arrangement.
- To INFLUENCE and BROADEN optometry's value proposition, to include the role of doctors of optometry as primary health care providers, the scope of services available from doctors of optometry, and the challenges to access presently encountered by our patients and practitioners, to health plan stakeholders, employers and employer coalitions, benefit consultants and other stakeholder groups.
- To SERVE as a consultant and liaison to insurance plans, managed care systems, large employers, employer coalitions and other organizations involved with third party health care delivery.
- To EDUCATE member doctors of optometry and affiliates on all aspects of third party eye/vision care programs, including conventional health care insurance, government health care programs, and ERISA self-funded, employer health plans.
- To FACILITATE the development of third party expertise within each affiliated association in order to prepare them to assist members with their payer and purchaser relationships.
- To SERVE as a clearinghouse of information on third party issues and national health care delivery systems.
- To COMMISSION research and studies that help to advance the optometry profession.
- To PROMOTE the AOA as the voice of optometry to national code setting organizations, and to ADVANCE optometry's interests in national coding decisions.
- To ENCOURAGE the proper use of national guidelines including the International Classification of Diseases (ICD), Current Procedural Terminology (CPT) Healthcare Common Procedure Coding System, and the Documentation Guidelines for the Evaluation and Management Services.
Have a third party question? Email TPC or call 703.837.1014.
With new laws enacted by Congress, more legislation anticipated this year at the federal and state level, an expectation of additional federal regulation, and a recent Supreme Court ruling affecting the reach of longstanding insurance law, the AOA’s Third Party Center (TPC) Executive Committee seeks to use new and traditional paths to challenge undesirable policies and actions of health and vision plans. The TPC seeks feedback on the issues that AOA members are most concerned about for 2021, to pursue with a renewed focus in the coming year as the dust of the COVID-19 pandemic hopefully begins to settle.
Some vision plans are known to “claw back” payments from claims by recouping the funds from current claims. Many of these claims had been submitted a number of years in the past, and were often correctly billed. The AOA believes this violates many states’ insurance claim recoupment laws, which set limits on how long an insurer has to recoup money from overpaid claims (often 18 months or less). The AOA began collecting examples of these clawbacks in 2020 right before the start of the COVID-19 pandemic and will pick up this advocacy objective again in 2021. The AOA seeks to question this poor business practice, in coordination with state affiliates, in the states where these plans are most blatantly violating insurance recoupment laws.
If you have experienced a clawback from a vision plan for a years-old claim, please provide documentation (redacted to protect any confidential patient information) to the AOA’s Third Party Center at email@example.com.
Doctors of optometry, as well as other health care providers, have been impacted by health plan downcoding schemes where the plan automatically downcodes claims submitted for office visits or with certain modifiers for certain doctors who have been labeled by the plan for using some codes at greater frequency than peers, or greater than the plan believes is prudent. It is based on an undisclosed algorithm, likely without a review of the doctor’s actual medical record and documentation, and impacted doctors are notified by letter. Doctors can appeal the downcoding decision, and if they are successful in enough appeals, they will be taken out of the program.
It is the AOA’s position that downcoding without reviewing the medical record is inappropriate and that third party payers should pay the claim or deny the claim based on the coverage and clinical needs of the patient, as documented in the medical record, and not make coverage decisions based merely on the identity of the doctor who submitted the claim. The AOA directly advocated on this issue prior to the pandemic and asked health and vision plans to cease these and other administrative hassles during the national health emergency but has heard that the practice is still occurring in many regions. AOA will continue to work on a resolution in 2021. If you are subject to a payer downcoding program and would like AOA guidance on appeals or coding, then email AOA’s Third Party Center at firstname.lastname@example.org.
Some health plans continue to steer doctors of optometry to credential with a vision plan instead of the health plan even though ophthalmologists may continue to contract directly with the health plan. In other situations, a doctor of optometry might be dropped from a medical plan network in favor of a network of optometrists rented from a vision plan.
If you have experienced this, then please send a report to email@example.com.
Combating Health and Vision Plan Anticompetitive Practices
While AOA regularly warns doctors not to engage in prohibited, anticompetitive conduct with competitors, the AOA is concerned that health and vision plans might have participated in anticompetitive practices that were exempt from federal oversight over the years. Recent changes in law have leveled the playing field. If you or your practice are experiencing anticompetitive behavior from a health or vision plan, please report this to the Third Party Center at firstname.lastname@example.org.
A Medicare vision benefit expansion was cut from the Build Back Better Act, but now advocates shift focus to avoiding nearly 10% cuts to Medicare reimbursement on Jan. 1, 2022.
Adding optometry to the list of hospital outpatient services and inpatient consults not only realizes the high level of contemporary, optometric medical eye care doctors of optometry provide, but also leverages’ communities primary eye care providers in a way that is mutually beneficial for patients, hospitals and doctors.