AOA advocacy efforts return more than $7.5 million to members

When Andy Stephens, O.D., received a request for information from 150 charts from Datavant, a third party contracted by Aetna, to complete Medicare Advantage risk adjustment audits, he devoted significant staff hours to complete the request. This wasn’t an uncommon request, but this year, there was a difference—Dr. Stephens knew he could negotiate for reimbursement for his staff’s time. He was reimbursed a total of $6,600.  

“Through participation in the AOA Third Party Center committee, I learned from Dr. Steve Eiss that you could negotiate the number of charts and ask for reimbursement for your staff time in processing these requests,” Dr. Stephens says. “Had I not had the connection through the AOA, I would not have known to do this.” 

Dr. Stephens is just one doctor who has benefited from the AOA’s advocacy. At Optometry’s Meeting®, AOA leadership announced they have returned more than $7.5 million to doctors of optometry and their practices. The ongoing reimbursement is the result of dozens of issues resolved involving improper denials, inappropriate takebacks, baseless plan administrator decisions, and unfair exclusions for doctors of optometry by vision benefit managers (VBMs) over the past 24 months.  

“We’ve helped doctors get paid for improperly denied YAG procedures, reversed inappropriate contract terminations, and fought to remove providers from unjust downcoding programs,” AOA President Jacquie M. Bowen, O.D., said in a presentation at Optometry’s Meeting. “Every day, we’re directly interfacing with plans to resolve credentialing problems, claim delays, and coverage inconsistencies. Our commitment is clear: we are here to help individual doctors, we are transparent in our work, and we welcome accountability for the results we deliver.” 

Fighting denied claims changes the industry at large 

Along with time-intensive records requests, several other actions make running a successful practice more difficult. The AOA is also helping practitioners fight against unfair denials from health payers and downcoding that delays or reduces payment and diverts staff resources away from serving patients. 

As health insurance payers default to denials, many doctors question the feasibility of fighting denied claims. It costs $43.84 for a doctor to fight a single denied claim, Dr. Bowen said. After fighting the denied claims, 97% of claims are paid, she said, but not before costing doctors $19.7 billion annually in administrative labor. 

Instead of expecting doctors to shoulder this undue financial burden, the AOA acts as an extra administrative staff member to fight claim denials, inaccurate network directories, or the host of other issues that arise. Often, it only takes one doctor’s report to uncover a problem that affects doctors statewide, or even nationwide, such as new codes and system updates that can lead to claim denials across the industry. 

Dr. Stephens’ experience has already helped his colleagues in Kansas. “I have been able to share this information with our Third Party Committee to inform our members,” he says, “I’ve also been able to inform colleagues in other states on this issue personally.” 

As awareness of providers’ rights to reimbursement and the resources AOA provides spreads, the potential for more fair practices grows. The AOA is fighting for every dollar that health payers owe doctors of optometry. These advocacy efforts are creating better access to care for patients by allowing doctors to focus on patient care rather than administrative hurdles to get paid. 

How to respond to Medicare Advantage records requests  

The AOA encourages doctors of optometry to take a strategic approach to these requests.  

• Call the phone number listed on the request (it might be for a third-party company that is contracted by the health plan) and ask for a deadline extension.  
• Ask to reduce the number of records you need to submit to comply with the request.  
• Ask for reimbursement.  

 For more information on responding to risk adjustment audits, doctors of optometry can access the AOA resource “Risk Adjustment Audits/Records Requests-How To Respond.” For questions about how to get reimbursed for time and effort spent in responding to records requests, contact stopplanabuses@aoa.org.