Texas doctor successfully challenges Aetna’s policy on panels

May 6, 2015
Doctors of optometry will be able to get direct medical contracts with insurer.

Texas doctors of optometry no longer have to go through a vision care provider to contract directly with health insurers, thanks to the profession's advocacy efforts.

"You can directly credential with an insurance company independent of a vision care provider."

Responding to a complaint issued by Peter Zanella, O.D., a practicing doctors of optometry in Southlake, Texas, the Texas Department of Insurance (TDI) on May 1 fined Aetna Life Insurance Company $25,000, ruling that the insurer had violated state law by issuing certain restrictions against doctors of optometry.

The state insurance commissioner found that Aetna had not complied with two statutes. One statute allows doctors of optometry access to a health plan's medical panel if they already serve on the plan's vision panel. The other law prevents an insurance company from requiring an OD to accept any particular vision plan in order to be credentialed with the medical plan.

"Together with the TOA [Texas Optometric Association], our AOA Third Party Center experts see this ruling as a landmark affirmation of eye health access laws in Texas," says AOA President David A. Cockrell, O.D. "With this win in hand, AOA and state associations gain new momentum in the effort to defeat unfair and illegal payer practices and a new opportunity to press even harder for full integration of the essential care we provide."

Doctors of optometry had restricted access to panels

Prior to this ruling, Aetna's medical panel had been closed to Texas doctors of optometry for direct credentialing.  The only way an optometrist could join Aetna as an in-network provider was to join EyeMed as a provider—and sign a contract addendum that outlined Aetna's policy on medical panel access. 

Once doctors of optometry signed the contract, they could no longer bill directly through Aetna for routine vision codes.

"If an optometrist attempted to call Aetna to try to get on the medical panel, the response was invariably to 'call EyeMed.' That's a situation that should not be occurring," says Thomas A. Lucas Jr., O.D., president of the Texas Optometric Association. "Not every practice can accept EyeMed or wants to accept EyeMed, but Aetna patients should not be denied access to medical eye care by their optometrists when they need it."

TDI's order states that any therapeutic OD who serves on Aetna's vision panels should be allowed to fully participate as a provider on the insurer's medical panels. Aetna was also directed to include a therapeutic optometrist on its medical panels, and train its provider relations department and customer service representatives on state insurance laws that apply to therapeutic doctors of optometry.

This ruling means Aetna members throughout Texas will be able to receive comprehensive eye health and vision care services from their optometrist—including medical eye care services covered by Aetna health plans, says Stephen Montaquila, O.D., chairman of the AOA Third Party Center Executive Committee.

Achieving this win for optometry wasn't easy. Aetna had initially denied Dr. Zanella's request for direct credentialing with the insurer, and his complaint was rejected twice before an investigator did an initial screening. Having the support of his state optometric association—and a good relationship with state regulators—helped his case. "I couldn't have done this without the help of TDI," he says.

Advice to doctors of optometry: Know your statute

Dr. Zanella's advice to doctors of optometry in other states: Know your insurance law. "Know what parts of the law apply to optometry specifically. If you don't know it, you can't enforce it."

This isn't the first time optometry achieved such a win in Texas. Two years ago, TDI issued a similar order against Cigna, following a two-year effort by Stephen Hlis, O.D., to pursue a complaint against the insurer. Dr. Lucas hopes that other state associations take steps to prioritize medical panel access for doctors of optometry.

"I know that this is a priority for the AOA. Throughout the time that we've been working on these issues, Texas has been the beneficiary of substantial support from the AOA leadership, committee volunteers and staff. Forcing change through statutory and regulatory mechanisms takes time, but you have to keep putting one foot ahead of the other," Dr. Lucas says.

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