How to successfully navigate Medicare Advantage plans
Opportunities exist to capitalize on the rapidly expanding market of Medicare Advantage (MA) Plans—provided that you know how to navigate these plans, and know where to seek help.
AOA says its members are seeing growth in MA plans in their respective states, and as a result, are caring for more patients covered by these plans. According to the latest statistics from the Kaiser Family Foundation, enrollment in MA plans has risen by 41% or 4.6 million lives since the enactment of the Affordable Care Act. More than 15 million beneficiaries are enrolled in MA plans in the United States, making up about 30% of the total Medicare population.
Gradually over time, more MA plans have been offering embedded vision benefits to help market their plans to Medicare beneficiaries. Today, roughly 80 to 90% of MA plans cover routine eye exams, and according to a Better Medicare Alliance study, about 60% cover vision hardware. Other research suggests that, among seniors aware of this coverage, nearly 80% are satisfied with their MA vision benefits.
This emphasis on vision coverage is attractive to doctors, who join such networks to expand their Medicare patient base—a cohort often in need of medical eye care. MA plans, however, often use restrictive or narrow networks to artificially limit access to care and utilization of services. Doctors of optometry often find out that they have given up many of their rights as Medicare providers for their MA patients.
Where roadblocks with MA plans exist
April Jasper, O.D., who practices in West Palm Beach, Florida, says she's able to participate with many of the state's MA plans, though a lot of them pay doctors at much lower rates than Medicare fee-for-service. "Every plan is different—however, more and more are creating very narrow networks—eliminating all different medical specialists" including doctors of optometry, she observes.
Not all doctors of optometry are seeing such barriers to participation. In Minnesota, where Greg Kraupa, O.D., practices, "there really has not been a significant narrowing of the provider panels. It is my suspicion that narrower provider panels may be a consideration in the future if the MA plans find they are losing money. So far, that has not happened," says Dr. Kraupa, a past president of the Minnesota Optometric Association who served on AOA's Eye Care Benefits Committee for 17 years.
One problem Dr. Kraupa has seen is MA plans placing lower value and reimbursement on routine and preventative eye care. "When we provide medical eye care we get fair reimbursement, but that is not always the case with the routine/preventative care," he observes.
There are signs that federal regulators want to improve upon the program—in early April, the Centers for Medicare and Medicaid Services announced that it would be increasing MA rates by 1.25%, based on higher estimates of fee-for-service spending. While the future of MA plans were uncertain just a few years ago, these plans seem to have emerged from partisan politics to general acceptance.
While MA plans are prohibited from discriminating against providers based on their licensure, AOA continues to fight for better oversight of MA plans and encourages members to report instances of discrimination, such as in reimbursement or network selection. In the meantime, there are things doctors of optometry can do to better navigate these plans:
- Emphasize your worth
doctors of optometry need to make this clear not only to patients but to their fellow providers. Providing excellent care to your patients will increase your visibility, Dr. Jasper advises. Doctors of optometry should also work to build relationships with other primary care doctors and pediatricians. One way to do this is to send reports to these primary care providers regarding their patients' exam findings, she says.
- Ask your patients for help
If you find yourself cut out of a plan, find out which patients are affected by that decision, says Dr. Kraupa. "Ask them to send a letter to the plan asking for you to be added to the provider panel. Third party payers do listen to their enrollees."
- Seek assistance from your third party center
Contact AOA's Third Party Center for assistance, or reach out directly to your state optometric association's third party committee. Look to develop a relationship with them before problems arise, Dr. Kraupa says. It also helps to find ways to help the third party payers with their challenges. "If you scratch their back today, they will be more inclined to scratch yours in the future," he says.
- Know your chair cost
Every OD should be encouraged to calculate and understand what it costs to see a patient. Don't sign up for participation in a plan that doesn't meet or exceed your chair cost. "If everyone follows this simple rule, life will be better for the entire profession," Dr. Kraupa recommends.
Members can access new, template appeal letters to assist in payer denials and patient communications, as well as attend an #AskAOA webinar on addressing payer clawbacks and denials.
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