When getting paid will cost you
Electronic fund transfer (EFT) fees aren’t the latest way for plans to nickel-and-dime provider payments, yet a recent exposé fortifies advocates’ calls to eliminate such predatory fees threatening practices and patients alike.
Published in August, an investigative article from the nonprofit ProPublica shed light on the burgeoning multibillion-dollar electronic payment processing industry rooted in the middle of how health plans pay providers for their services. With as many as two-thirds of medical practices compelled to pay EFT fees they did not agree to, just to get paid, advocates are sounding alarms over the once prohibited practice. Such industry-wide calls for action come as optometry’s advocates increase their own pressure on health and vision plans over fair competition and valuation of comprehensive optometric care.
There are plenty of reasons doctors are furious with the insurance industry. Insurers have slashed their reimbursement rates, cost them patients by excluding them from their provider networks, and forced them to spend extra time seeking pre-authorizations for ever more procedures and battling denials of coverage.
Paying fees to get paid is the final blow for some. — The Hidden Fee Costing Doctors Millions Every Year, ProPublica.
As ProPublica continues, some health plans require utilization of third-party processors that can charge anywhere from 2% to 5% in fees for electronic transactions. And even when doctors try avoiding fees by requesting check payments, ProPublica notes, some doctors assert that insurers have resumed fee-inducing electronic payments anyway.
Frustratingly, this was a settled subject. The Affordable Care Act accelerated a paper-to-electronic transition and allowed for a standardized EFT method for provider reimbursement. Yet in 2017, the Centers for Medicare & Medicaid Services (CMS) removed guidance that prohibited plans and payment processing vendors from “engaging in unfair business practices that do not support an efficient healthcare system,” notes a Medical Group Management Association issue brief. Hence the crux of ProPublica’s investigation.
Since 2017, fees on electronic payments have become increasingly commonplace, says Steve Eiss, O.D., AOA Third Party Center chair. It’s especially true of medical plans utilizing a service where payment is being issued through a credit card-type payment, resulting in the provider having to pay additional fees to obtain payment—on top of the discount the insurance plan applies to the fee. Almost all optometrists who submit claims to medical payers will have encountered this situation, Dr. Eiss says.
“The unfortunate reality of this is that we are seeing an additional intermediary entity that has no role in providing care to the patient, removing funds from the system that could be used to better care for the patient,” Dr. Eiss says.
So, what is there for optometry practices to do? Dr. Eiss says when payers provide this type of payment, consider refraining from processing the payment initially. Instead, contact the payer and request a form of payment that does not involve additional charges. It’s recommended that providers thoroughly read their provider agreements before signing and request that any of these types of fees be removed, Dr. Eiss says.
For its part, the AOA Third Party Center has advocated on behalf of doctors of optometry to ensure there are no cost options to being paid, he says.
“We will continue to advocate for fair payment practices and recommend members and state associations reach out to the AOA Third Party Center whenever they encounter these kinds of roadblocks,” Dr. Eiss says.
So, too, doctors should connect with their state associations if they encounter this issue, Dr. Eiss recommends, as several states already limit these kinds of fees, such as New Mexico and Maryland.
How Colorado won a ‘fee-free method’ of compensation for doctors
Colorado is another one of those states. In 2023, Colorado’s legislature learned how the state’s medical providers incurred fees, such as credit card processing fees, to receive insurance payments for services provided and took up H.B. 23-1116.
Supported by the Colorado Optometric Association (COA), H.B. 23-1116 required insurance companies to not only offer at least one fee-free method of payment to the provider, but also eliminate restrictions on payment methods that would make it so the only acceptable payment method was by credit card.
H.B. 23-1116 also outlined requirements on carriers; namely, if the carrier initiates a payment to a provider using (or changes the payment method to) electronic funds transfer payments, e.g., virtual credit card payments, then the carrier must:
- Notify the provider of any associated fees with this payment method.
- Advise the provider on available payment methods and how to choose those methods.
- Remit an explanation of benefits with each payment.
“There has been a rapid increase in these kinds of fees nationwide since 2018, and we’re appreciative this important law was passed,” says Jason Ortman, O.D., AOA Third Party Center and COA member.
What AOA, affiliates are doing to challenge vision plans
Tens of millions of Americans rely on their local doctors of optometry for their comprehensive eye health and vision care needs, and despite historic advancements in optometry’s scope, plans haven’t sufficiently kept pace. In fact, compounded by increased costs and new challenges to care delivery—from supply chain disruptions to staffing issues—plans’ stagnant pay scales put optometry practices in a difficult place.
“Health and vision plans are stuck in the 1990s,” wrote AOA President Ronald L. Benner, O.D., in AOA Focus. “They have not adapted and grown with the care we deliver but found a pathway to increase their profits and, in turn, hold back optometry’s momentum. In short, they publicly reinforce the quality care we deliver while devaluing our profession by continuing to follow an outdated model for how doctors are compensated for the essential care we provide.”
The AOA and affiliates understand this dynamic and are advocating for an equitable system that fairly values optometric care. Among recent actions, the AOA has:
- Supported federal scrutiny of the vision benefit manager (VBM) market. In August, the U.S. House Committee on Oversight and Accountability Chair James Comer, R-Ky., issued a request for information from the Federal Trade Commission to conduct oversight of the agency’s role in preventing unfair and harmful marketplace practices, especially given consolidation in the vision insurance market.
- Continued direct dialogue with plan CEOs. The AOA keeps delivering a message focused on valuation of care, benefits coordination and resolution of barriers to care delivery, as well as other member concerns.
- Backed affiliates’ advocacy to update state laws. Multiple states, including Texas, Nevada, Illinois and Georgia, enacted vision plan laws this year with more affiliates looking to take action.
- Championed federal legislation and regulatory crackdown. Jointly backed by the AOA and American Dental Association (ADA), the Dental and Optometric Care (DOC) Access Act, H.R. 1385/S. 1424, remains priority legislation to curb plan abuses on a federal level. Additionally, the AOA’s advocacy with the CMS and members of Congress aided in the targeting of Medicare Advantage scams, as well as attention on supplemental vision coverage under the federal program.
- Built alliances with physician and patient organizations. In addition to the ADA, the AOA allied with the Patients Rising advocacy organization to help bolster calls for Congress to cease increasingly harmful VBM abuses.
Lastly, the AOA continues to monitor and review plan challenges alongside its anti-trust experts and provides enhanced transparency of these actions through the AOA’s Health and Vision Plan Action Report. This accounting of the AOA’s plan advocacy can be found in members’ daily First Look emails.
If you or your practice experiences challenges associated with a health or vision plan, please report this to the AOA Third Party Center at email@example.com.
Mirroring some of the AOA’s longstanding agitation over vision plans’ abuses, the Sept. 26 lawsuit by Total Vision LLC (and Total Vision, P.C.) alleges unfair competition, monopolization, tying and intentional interference with prospective business relations. Total Vision LLC supports 59 independent practices in California.
The AOA and affiliates in Illinois and Georgia score wins against vision plan abuses in a year in which doctors of optometry are making inroads across the country. When all else failed, including talks with the plans and appeals to one state’s insurance commissioner, affiliates did the hard work of helping push through bills in their legislatures that address the abuses.