AOA Third Party Center

Payer Advocacy Goals

1. The AOA is demanding that vision plans fix their inadequate valuation of the essential care we deliver. Reimbursement must fully reflect increased costs due to inflation and COVID-related protocols and mandates.
2. The AOA is urging Federal officials to increase enforcement of national provider anti-discrimination laws, which specifically ban licensure-based restrictions on participation, coverage and reimbursement, including for biased ERISA plans.
3. The AOA is insisting that health plans end the tying of vision plan credentialing and participation requirements. We are pushing these plans to better hold payers accountable by requiring that a significantly higher percentage of their resources are devoted to patient care, rather than profits.
4. The AOA is spotlighting the scandalous failures of the Medicare Advantage plans that are misleading seniors and needlessly limiting their access to care. AOA is now pushing Congress to enact the Seniors Timely Access to Care Act to reform the broken prior authorization system to cut unnecessary care delays for patients and ease administrative burdens on doctors.
5. The AOA is, through a united advocacy front with our American Dental Association partners, building support on Capitol Hill and in the Administration for legislation before Congress (the bipartisan and bicameral Dental and Optometric Care “DOC” Access Act) to outlaw documented plan abuses, including restrictions on lab choice and forced discounts. (Already, in 2020, through our work with the dentists and other provider groups, Congress successfully eliminated the McCarran-Ferguson anti-trust exemption that the insurance industry enjoyed for 75 years.)
6. The AOA is championing the need for the Medicare reimbursement system to be revamped so that doctors are more fairly paid for the quality care they provide and aren’t required to jump through unnecessary hoops and push paper to avoid year-over-year reimbursement cuts.
7. The AOA is partnering with affiliates in state legislatures nationwide to enact legislation, which allows doctors of optometry to best serve their patients eye health and vision care needs, by enabling critical statutory protections like lab choice and removing untenable contractual requirements.
8. The AOA is actively engaged with national associations like the National Council of Insurance Legislators (NCOIL), working to defeat dangerous model legislative language proposed by the National Association of Vision Care Plans (NAVCP).

Have a third party question? Email TPC or call 703.837.1014.

Third Party Center Seeks Feedback on Health and Vision Plan Difficulties

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.

Clawbacks

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 stopplanabuses@aoa.org.

Downcoding

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 stopplanabuses@aoa.org.

Credentialing

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 stopplanabuses@aoa.org.

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 stopplanabuses@aoa.org.