Thoughts?

[kcount]

http://corneroptical.blogspot.com/20...-question.html

[braheem24]

Crying in the rain?

Whistling in the wind?

Voting for a Democrat in Texas?

I think your efforts would be better spent elsewhere, ie soliciting the large businesses in your area directly.

[Robert Martellaro]

Be careful what you wish for...

This works for me.

[kcount]

Thanks Robert. I actually file direct to VSP for the out of network benefits. The hang up is that the reimbursements are less than if your in-network. In the end I wrote the piece about a week ago after calling Humana's vision care plan and being told it was another OD only outfit (read: OD only if your an owner). This is simply one of those things that drives me nuts.

[uncut]

Any chance you could set up a company for the explicit purpose of complying with their requirements?

[Audiyoda]

VSP (and Humana) are privately held businesses - you play by their rules. But I'm still wondering why you care?

And VSP's out-of-network payment is very similar to in-network - except they pay for lenses which they don't in-network. I've worked in plenty of VSP offices, here's a common scenario for a common signature plan seen in my area (numbers have been changed so any lingering consumers aren't confused):

$100 frame benefit
Basic CR-39 covered
OoP on PAL $90
20% of U&C on all upgrades

So the patient picks a $150 frame, clear poly premium PAL w/AR

Patient OoP is $50 on the frame, $160 on the poly PAL (premium PAL has a different pay schedule), $80 on AR for a OoP total of $290

When VSP send you your monthly reimbursement numbers this is what you see:

Patient XYZ (same patient as above)
Frame: $X paid to office
Patient overage on plan: -$Y remitted from account
Administrative charges: .015*(X-Y)=Z
Total to office: $Z

Your total gross revenue from this order would have been $500 - instead it's $240 - or less than 50%.

As a VSP member office you accept the patient's co-pays on lenses and add-ons as reimbursement plus what VSP pays for frames. What VSP neglects to tell you is they have a formula for each signature plan - that formula determines how much each subscribers OoP should be. If your patient is over that number (in this case the patient was) then VSP will take that away from you because in their convoluted mind you shouldn't upsell their subscribers. Even if you aren't hit with a overage charge, your overall discount on this order is 42%.

Now, same plan but reimbursement is out-of-network.

Patient still picks a $150 frame, clear poly premium PAL w/AR. Your total charge is $500 for this pair. Patient asks if you will submit their paperwork and bill them for the rest - but you tell the patient you're more than happy to simply take what they would have paid in-network so the patient pays $290 and leaves happy. You turn around and submit for reimbursement to VSP - VSP will pay you $60 towards the frame, $85 for the PAL, and $60 for poly. Now your gross revenue from that order is $495 or a total markdown of 1%.

Again, this numbers are all theoretical - but within reason to basic signature plans.

I will never figure out why anyone would want to be in-network with VSP when it's so profitable to be out-of-network. Simply advertise that you accept Out of Network Reimbursement for VSP and get the word out. The only thing you need to know is if the patient's plan allows for out-of-network reimbursement - and nearly all signature plans do.

[Chris Ryser]

VSP (and Humana) are privately held businesses - you play by their rules. But I'm still wondering why you care?

Now your gross revenue from that order is $495 or a total markdown of 1%.

Again, this numbers are all theoretical - but within reason to basic signature plans.

I will never figure out why anyone would want to be in-network with VSP when it's so profitable to be out-of-network. Simply advertise that you accept Out of Network Reimbursement for VSP and get the word out. The only thing you need to know is if the patient's plan allows for out-of-network reimbursement - and nearly all signature plans do.

If above simple explanation actually works, I would not care about a small percentage difference of gross revenue.

[bhess25]

just shoot over here to ohio where VSP pays a ton for in network. They pretty much cover it all with the plans i use to see at the O.D.'s office. Now i work @ a small wholesale lab/ dispensary where we accept VSP, however its a reimbursement plan (people dont like that so much). Ohh and if you get bored try calling VSP and ask them why a big chain (we will just call it EM, I started out here in the lab, then on the "retail floor") is in network (ohh and that chain is NOT owned by O.D.'s), and it isn't a reimbursement plan. Too bad fairness isn't a law. Im really surprised an optician has not had their day in court with VSP yet, i could see this being called discrimination and with the right attorney they could win.

[kcount]

@audi You just laid out how I work VSP as an 'Independant Provider'. When you call VSP for the benefits they'll tell you what the in-network coverage is and then the out-of-network reimbursements. Do a comparison of the two and it's pretty easy to see how to play the game. The fun bit is when you can provide better products than in-network with better service along side it. I have a family that moved to me from an in-network office simpy because of my service. I have said it time and time again, eyewear and exams are widgets. The public can purchase both anywhere for less. What I sell is me. The only truely unique product in my office. That being said, in-network providers get on the panel list and thats what you want. The amount I spend in advertising is equal to what the insurance plans would take off the top.

[kcount]

Any chance you could set up a company for the explicit purpose of complying with their requirements?

OD is a no go on that plan. Otherwise it would have already been done.

[John@OWDC]

kcount, really nice post and a very interesting subject.

Sadly, this comes down to, could your team of lawyers beat up their lawyers?
Do you really want to take them on?

Everything you say and every point you make is 100% valid but as someone else stated it is their world and you have to play by their rules. If you are only interested in preaching to the choir then we can all be supportive for you...

At first I actually thought, well yes it does matter who owns the fixtures, however if an OD holds a national degree and a national certification and meets nationally recognized standards of care then it does not matter in the least who owns the building.

As to the owner being an optician that is meaningless since opticians are not part of a recognized national license or held to any standard of education. If that was a criteria I would rather have the building owned by a nurse or maybe even better a CPA, heck maybe even a plumber.

[Judy Canty]

Hire a retired MD as your Medical Director and have the OD work for the MD. I have a couple of friends here that use that strategy very profitably.

[Audiyoda]

@audi You just laid out how I work VSP as an 'Independant Provider'. When you call VSP for the benefits they'll tell you what the in-network coverage is and then the out-of-network reimbursements. Do a comparison of the two and it's pretty easy to see how to play the game. The fun bit is when you can provide better products than in-network with better service along side it. I have a family that moved to me from an in-network office simpy because of my service. I have said it time and time again, eyewear and exams are widgets. The public can purchase both anywhere for less. What I sell is me. The only truely unique product in my office. That being said, in-network providers get on the panel list and thats what you want. The amount I spend in advertising is equal to what the insurance plans would take off the top.

Remember, there are two panel lists (just like there is with Eyemed). Getting on one is easy - getting on the good one, not so much.

And you will be amazed at how much a little word of mouth will work for you once it gains some momentum. You just need a few people from a larger local employer - do as I've outlined and they will do the advertising for you. And if you make it worth their while - as in an additional discount for every referral they send you - you're golden.

[kcount]

Hire a retired MD as your Medical Director and have the OD work for the MD. I have a couple of friends here that use that strategy very profitably.

Ok now you've lost me.

[racethe1320]

just shoot over here to ohio where VSP pays a ton for in network. They pretty much cover it all with the plans i use to see at the O.D.'s office. Now i work @ a small wholesale lab/ dispensary where we accept VSP, however its a reimbursement plan (people dont like that so much). Ohh and if you get bored try calling VSP and ask them why a big chain (we will just call it EM, I started out here in the lab, then on the "retail floor") is in network (ohh and that chain is NOT owned by O.D.'s), and it isn't a reimbursement plan. Too bad fairness isn't a law. Im really surprised an optician has not had their day in court with VSP yet, i could see this being called discrimination and with the right attorney they could win.

Let's call it EM ? aka Mark L....? his battle was fought in court and he kept his in network status thanks to a decision made by a state other than where you live. Several practices meeting the description you make are in network with VSP. Not sure why so many here who are against managed care complain about not being able to participate. Many more speak ill of it, yet continue to gladly cash those checks though too. I will salute those that do neither for at least they walk the walk.

Kcount, well written article.

[kcount]

Let's call it EM ? aka Mark L....? his battle was fought in court and he kept his in network status thanks to a decision made by a state other than where you live. Several practices meeting the description you make are in network with VSP. Not sure why so many here who are against managed care complain about not being able to participate. Many more speak ill of it, yet continue to gladly cash those checks though too. I will salute those that do neither for at least they walk the walk.

Kcount, well written article.

Race, thank you for the compliment. It's simply a perspective. In the end the part that upsets me the most is that the OD in my office, who until beginning with me was a VSP Dr. Now she is seen as less by this same company because of who signs the lease. The reality is that my office will survive without panel provider status, but it would certainly be easier otherwise. In the meantime we'll remain an 'Independent Provider'.