Medical Plans?

[bear0651]

I have heard alot in this forum about how it is necessary to get on the insurance medical plans to be successful and to make a decent living with optometry. I seem to be a little confused, is this the same as vision plans? Or are they 2 different things entirely?

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[KHE]

I have heard alot in this forum about how it is necessary to get on the insurance medical plans to be successful and to make a decent living with optometry. I seem to be a little confused, is this the same as vision plans? Or are they 2 different things entirely?

AAAAAAAAAIIIIIIIIEEEEEEEEEEEEEEEEEEEE!!!!!!!!!!!!!!!!!!!!!!!!!!!!

It is clear that I am failing here.

OK! WHOEVER THAT SPAZZ IS WHO IS ALWAYS "BOOKMARKING" THREADS, NOW IS YOUR CHANCE TO DO IT FOR A REASON!!!

*START BOOKMARKING NOW*

"Medical" and "Vision" insurances are two COMPLETELY DIFFERENT things. You will always be able to get onto "Vision" plans, but there are significant parts of the country where you will not be able to get onto "Medical" plans so unless you want a career retailing eyewear and performing routine exams on routine patients, you better find yourself an area where you can be admitted onto MEDICAL plans!

*END BOOKMARKING NOW*

 

[prettygreeneyes]

AAAAAAAAAIIIIIIIIEEEEEEEEEEEEEEEEEEEE!!!!!!!!!!!!!!!!!!!!!!!!!!!!

It is clear that I am failing here.

OK! WHOEVER THAT SPAZZ IS WHO IS ALWAYS "BOOKMARKING" THREADS, NOW IS YOUR CHANCE TO DO IT FOR A REASON!!!

Cleansing breath in, cleansing breath out...

He/she is a new member and may not be familiar with your prolific posting history on the subject of OD exclusion from medical insurance panels. Give 'em some time... they'll catch up.

 

[JeffChou]

AAAAAAAAAIIIIIIIIEEEEEEEEEEEEEEEEEEEE!!!!!!!!!!!!!!!!!!!!!!!!!!!!

It is clear that I am failing here.

OK! WHOEVER THAT SPAZZ IS WHO IS ALWAYS "BOOKMARKING" THREADS, NOW IS YOUR CHANCE TO DO IT FOR A REASON!!!
........

Yes, please subscribe to the thread by logging in and then clicking on the "thread tools" button at the top of the thread. It's always a letdown when I excitedly see threads with recent posts which turn out to be nothing. I can't take the emotional vacillation (maybe it's time to admit addiction to SDN).

 

[Ben Chudner]

AAAAAAAAAIIIIIIIIEEEEEEEEEEEEEEEEEEEE!!!!!!!!!!!!!!!!!!!!!!!!!!!!

It is clear that I am failing here.

OK! WHOEVER THAT SPAZZ IS WHO IS ALWAYS "BOOKMARKING" THREADS, NOW IS YOUR CHANCE TO DO IT FOR A REASON!!!

*START BOOKMARKING NOW*

"Medical" and "Vision" insurances are two COMPLETELY DIFFERENT things. You will always be able to get onto "Vision" plans, but there are significant parts of the country where you will not be able to get onto "Medical" plans so unless you want a career retailing eyewear and performing routine exams on routine patients, you better find yourself an area where you can be admitted onto MEDICAL plans!

*END BOOKMARKING NOW*

I don't get it. They are different? Could you explain it again?

 

[KHE]

I don't get it. They are different? Could you explain it again?

"SAY HELLO TO MY LITTLE FRIEND!!!!!!!!!!"

 

[Ben Chudner]

"SAY HELLO TO MY LITTLE FRIEND!!!!!!!!!!"

Ken, you know I couldn't resist.

 

[sco1styear]

While you two are joking around (and it is funny), I am beginning to see a pattern on this board where people don't seem to be answering questions. You docs have vasts amount of "real world" knowledge and understanding of things that us "students" and prospective students do not.
This person could be helped more by someone explaining the differences between vision and medical plans and providing examples of some of the larger plans in your area. Don't worry, you can still add in how important it is for us to get onto medical plans

 

[KHE]

While you two are joking around (and it is funny), I am beginning to see a pattern on this board where people don't seem to be answering questions. You docs have vasts amount of "real world" knowledge and understanding of things that us "students" and prospective students do not.
This person could be helped more by someone explaining the differences between vision and medical plans and providing examples of some of the larger plans in your area. Don't worry, you can still add in how important it is for us to get onto medical plans

For the record, I believe I have explained this difference a bunch of times in my (extensive) history of posting on this subject but it is such an important issue (in my opinion the BIGGEST one) that I will repeat it.

I think we all have a pretty good understanding of what medical insurance plans are because most of us have one. Blue Cross, Aetna, United Health Care, Cigna etc. etc. etc. This is the insurance plan you use when you go to the doctor, the hospital, get your lab work done, get your x-rays etc. etc. etc.

Most of us are also familiar with "dental" plans which are usually offered as an employee benefit SEPARATE from your medical insurance. Common ones are Guardian and Delta Dental. Many of you may have a dental benefit as well. In rare cases, your medical insurance may offer a dental benefit but the majority of times it is a rider to your medical insurance that is ADMINISTERED BY A DIFFERENT COMPANY than your medical insurance is.

Vision plans are the exact same thing. They are a benefit for ROUTINE eye exams and materials (glasses, contacts) that are normally provided as an additional benefit to your medical insurance plan. VSP, Specters, Eyemed etc. etc are some of the more common ones.

Ok........here it comes again...........

You must make sure that you can be admitted onto the provider panel for the major MEDICAL plans in your area of practice. With rare exception, you will always be able to get on any vision plan you want whenever you want. However, the same does NOT hold true for many medical plans in many parts of the country. Many medical plans do NOT allow ODs to bill (and therefore be reimbursed) for anything other than routine care. This is a catastrophe on so many levels that should be fairly obvious, but I'm happy to spell it out again if you want.

Is that clear enough? I'm not being sarcastic when I say that. What else would you like to know about this issue because it is the one that I believe is the single biggest issue facing optometry today, and yet for some reason it gets so little press. It is far bigger than Walmart, 1-800 contacts, OD oversupply (I believe it is a partial cause of OD oversupply actually) bickering with the ophthalmologists etc. etc.

For those of you in optometry school and those considering it, it is going to be THE issue for your generation. And it will either be your biggest failure, or your finest hour. That may sound melodramatic, but I believe it to be true, so please fire away any questions that you may have.

 

[sco1styear]

Thank you, no one could have explained it any better!

 

[bear0651]

Sorry KHC, I am new.....cut me some slack. I am very interested in the matter but I am very uneducated on the matter. I understand the difference now. I currently work at an Optometrist's office and from what you have explained it seems that they only accept vision insurance (VSP, wellcare, staywell, Compbenefits, and so on). What I guess I am asking is how do you get admitted onto the provider panel for the major medical plans? I currently live and work for an office in Florida. Also, do certain states allow and other states not allow Optometrists to get on the medical plans? Is it easier in some states than others? Sorry if this is posted in another thread. If so just direct me there

 

[Ben Chudner]

What I guess I am asking is how do you get admitted onto the provider panel for the major medical plans?

It's as easy as contacting the plan and asking for an application. That is, if they are accepting new providers, or if they will let an OD be on the panel.

Also, do certain states allow and other states not allow Optometrists to get on the medical plans? Is it easier in some states than others? Sorry if this is posted in another thread. If so just direct me there

If your state has an Any Willing Provider Law, like mine, then you cannot be exluded from medical plans on the basis of being an optometrist. If not, then it may be more difficult.

 

[mthomas2]

For the record, I believe I have explained this difference a bunch of times in my (extensive) history of posting on this subject but it is such an important issue (in my opinion the BIGGEST one) that I will repeat it.

I think we all have a pretty good understanding of what medical insurance plans are because most of us have one. Blue Cross, Aetna, United Health Care, Cigna etc. etc. etc. This is the insurance plan you use when you go to the doctor, the hospital, get your lab work done, get your x-rays etc. etc. etc.

Most of us are also familiar with "dental" plans which are usually offered as an employee benefit SEPARATE from your medical insurance. Common ones are Guardian and Delta Dental. Many of you may have a dental benefit as well. In rare cases, your medical insurance may offer a dental benefit but the majority of times it is a rider to your medical insurance that is ADMINISTERED BY A DIFFERENT COMPANY than your medical insurance is.

Vision plans are the exact same thing. They are a benefit for ROUTINE eye exams and materials (glasses, contacts) that are normally provided as an additional benefit to your medical insurance plan. VSP, Specters, Eyemed etc. etc are some of the more common ones.

Ok........here it comes again...........

You must make sure that you can be admitted onto the provider panel for the major MEDICAL plans in your area of practice. With rare exception, you will always be able to get on any vision plan you want whenever you want. However, the same does NOT hold true for many medical plans in many parts of the country. Many medical plans do NOT allow ODs to bill (and therefore be reimbursed) for anything other than routine care. This is a catastrophe on so many levels that should be fairly obvious, but I'm happy to spell it out again if you want.

Is that clear enough? I'm not being sarcastic when I say that. What else would you like to know about this issue because it is the one that I believe is the single biggest issue facing optometry today, and yet for some reason it gets so little press. It is far bigger than Walmart, 1-800 contacts, OD oversupply (I believe it is a partial cause of OD oversupply actually) bickering with the ophthalmologists etc. etc.

For those of you in optometry school and those considering it, it is going to be THE issue for your generation. And it will either be your biggest failure, or your finest hour. That may sound melodramatic, but I believe it to be true, so please fire away any questions that you may have.

Wow, as ignorant as I may sound right now... I did not know the difference. However, I am starting opt. school this fall. Please be patient with us that are just getting it. Remember you were there too. Thank you so much for sharing your valuable knowledge.

 

[KHE]

It's as easy as contacting the plan and asking for an application. That is, if they are accepting new providers, or if they will let an OD be on the panel.If your state has an Any Willing Provider Law, like mine, then you cannot be exluded from medical plans on the basis of being an optometrist. If not, then it may be more difficult.

This is bacially true, but there are a couple of very important caveats to that.

If you are in a state that is covered by an AWP law, you can still be excluded if a medical plan decides that they have too many of a particular type of provider.

Also, if the largest employer in your area is covered under ERISA, then any state AWP law is essentially meaningless.

The best example of this that comes to my mind, because I experienced it personally was the casino workers union plan when I lived in Las Vegas. This was a self funded plan covered under ERISA, not a traditional HMO or PPO like Blue Cross or Aetna. As such, even if Nevada had an AWP law (which it did not at the time, don't know if it does know, but I don't think so) it would not matter because the union plan would have still legally been able to deny ODs access to the plan.

And if you live in Las Vegas and you can't see casino workers for medical claims....well you can all pretty much guess how that works out.

 

[KHE]

Sorry KHC, I am new.....cut me some slack. I am very interested in the matter but I am very uneducated on the matter. I understand the difference now. I currently work at an Optometrist's office and from what you have explained it seems that they only accept vision insurance (VSP, wellcare, staywell, Compbenefits, and so on). What I guess I am asking is how do you get admitted onto the provider panel for the major medical plans? I currently live and work for an office in Florida. Also, do certain states allow and other states not allow Optometrists to get on the medical plans? Is it easier in some states than others? Sorry if this is posted in another thread. If so just direct me there

Let me make a suggestion....

Phone up your employer and ask him why he is not enrolled in any of the medical plans?

What does your office do with patients who have "medical" issues such as injuries or glaucoma or diabetic cases?

 

[KHE]

Wow, as ignorant as I may sound right now... I did not know the difference. However, I am starting opt. school this fall. Please be patient with us that are just getting it. Remember you were there too. Thank you so much for sharing your valuable knowledge.

I'm asking this next question with sincerity....

Have I not been clear enough in my extensive postings on this subject in the past for all of you "regulars" to NOT have known the difference between medical and vision plans?

If I have not, has there been any reason you have all not asked for clarification because I think that I HAVE been quite clear about the importance of this issue.

 

[IndianaOD]

I'm asking this next question with sincerity....

Have I not been clear enough in my extensive postings on this subject in the past for all of you "regulars" to NOT have known the difference between medical and vision plans?

If I have not, has there been any reason you have all not asked for clarification because I think that I HAVE been quite clear about the importance of this issue.

I believe the insurance issue is second only to oversupply of ODs. Students you must be active in the AOA and other optometric organizations and talk to your legislators when problems arise.

 

[bournehall]

Forget about vision and getting on medical plans. A student with less than three years or prospective student would be better off spending their time figuring how to get into another professional program. 4 years of college and 4 years of optometry to put up with this is simply idiotic.

While you two are joking around (and it is funny), I am beginning to see a pattern on this board where people don't seem to be answering questions. You docs have vasts amount of "real world" knowledge and understanding of things that us "students" and prospective students do not.
This person could be helped more by someone explaining the differences between vision and medical plans and providing examples of some of the larger plans in your area. Don't worry, you can still add in how important it is for us to get onto medical plans

 

[luckyfool]

Current ODs please indicate the state where you practice?

 

[bournehall]

I am trying to help you sco1st year. To begin with I want you to run, not walk, down the street to the medical units of UT and apply to another professional program. This you will bless me for in a few years. You can always sell the trial lenses and all that other stuff to some unsuspecting ideolgue who knows no better.

While you two are joking around (and it is funny), I am beginning to see a pattern on this board where people don't seem to be answering questions. You docs have vasts amount of "real world" knowledge and understanding of things that us "students" and prospective students do not.
This person could be helped more by someone explaining the differences between vision and medical plans and providing examples of some of the larger plans in your area. Don't worry, you can still add in how important it is for us to get onto medical plans

 

[sco1styear]

I am trying to help you sco1st year. To begin with I want you to run, not walk, down the street to the medical units of UT and apply to another professional program. This you will bless me for in a few years. You can always sell the trial lenses and all that other stuff to some unsuspecting ideolgue who knows no better.

#1 I am 3 months away from beginning my 4th year (woo hoo!)
#2 I am going into optometry because it is something I feel called to do - l don't feel I could be happy in any other profession and would do this even if I made $10,000 a year (similar to why people will always go into teaching even though it doesn't pay squat)

 

[sco1styear]

I'm asking this next question with sincerity....

Have I not been clear enough in my extensive postings on this subject in the past for all of you "regulars" to NOT have known the difference between medical and vision plans?

If I have not, has there been any reason you have all not asked for clarification because I think that I HAVE been quite clear about the importance of this issue.

I feel that you have been clear but it has been some time since this was discussed in depth. And I bumped the question off to you because I feel like this is your territory on this board

 

[Ben Chudner]

If you are in a state that is covered by an AWP law, you can still be excluded if a medical plan decides that they have too many of a particular type of provider.

True, but in my experience rare. In an AWP state, it does not make sense to exclude all providers in a specialty.

Also, if the largest employer in your area is covered under ERISA, then any state AWP law is essentially meaningless.

Unfortunately, this very true. There has been legislation introduced to put Medicare under ERISA which is very scary. To my knowledge it died without getting anywhere.

 

[bear0651]

It's as easy as contacting the plan and asking for an application. That is, if they are accepting new providers, or if they will let an OD be on the panel.If your state has an Any Willing Provider Law, like mine, then you cannot be exluded from medical plans on the basis of being an optometrist. If not, then it may be more difficult.

So they why doesn't evey optometrist apply to be on the Insurance plans? Is it just that they only accept a very small number of Optometrists to be providers?

 

[Ben Chudner]

So they why doesn't evey optometrist apply to be on the Insurance plans? Is it just that they only accept a very small number of Optometrists to be providers?

Applying is the easy part (well, not really if you have ever read one of those application ). In states that do not have Any Willing Provider Laws, insurance companies can legally refuse to allow OD's on the panel just because they are OD's. As Ken pointed out, even in states with AWP Laws, an ERISA plan can still legally refuse to allow OD's on the panel just because they are OD's. There is also the possibility that a plan is closed to all new providers, however, in my experience this is rare but I can only speak about the state of Washington. The main point of Ken's multiple posts, is that before you decide on a place to practice, you should make sure you are familiar with the situation. If you want to practice full scope optometry, you need to make sure that you can get onto medical plans in the area you want to practice in. This is because patients do not want to pay out of pocket for a visit or procedure that would be covered by their insurance. This means that if they have a choice between seeing an OD and paying out of pocket, or seeing an OMD and paying a $10 co-pay, they will choose the OMD. This will force you to simply spin and grin for the vast majority of your patients. If this is ok with you, and it is fine if it is, then it makes no difference where you practice.

 

[Ben Chudner]

Current ODs please indicate the state where you practice?

Washington State

 

[bear0651]

Applying is the easy part (well, not really if you have ever read one of those application ). In states that do not have Any Willing Provider Laws, insurance companies can legally refuse to allow OD's on the panel just because they are OD's. As Ken pointed out, even in states with AWP Laws, an ERISA plan can still legally refuse to allow OD's on the panel just because they are OD's.

Does anyone know which states do and do not have AWP Laws? Also which states are the easiest to get on the medical plans? Which states are the hardest?

 

[KHE]

Does anyone know which states do and do not have AWP Laws? Also which states are the easiest to get on the medical plans? Which states are the hardest?

This isn't even a state by state issue. This can vary even within a state. For example, in upstate New York, you may have lots of problems accessing plans whereas in downstate New York you may not. (I'm just using that as an example, I'm not sure what the insurance climate is in either upstate or downstate New York anymore)

What you need to do is figure out what town or city you want to practice in, find out who the 5 dominant medical carriers are in that town (you can usually get this from the state insurance commisioner or the local chamber of commerce), and then phone them up to ask if you can be admitted onto the panel.

 

[sco1styear]

I think this has been touched on before but maybe we could go over it again... If you go into practice for or with another optometrist that has already been practicing and is on the panels you want on, does this help your chances of being accepted or have no bearing at all? Does each doctor in a practice have to apply? Does being an employee versus a partner change anything?

 

[KHE]

I think this has been touched on before but maybe we could go over it again... If you go into practice for or with another optometrist that has already been practicing and is on the panels you want on, does this help your chances of being accepted or have no bearing at all? Does each doctor in a practice have to apply? Does being an employee versus a partner change anything?

If you go into practice with another OD who IS admitted onto the panels then it is generally much easier but not because they are on the plan themselves per se, but because if an OD is on the plan, then they are likely practicing in an area where it is relatively easy to get onto plans. However, you must make sure that you get credentialed as an individual provider so that if you leave, your credentials will be more easily transported.

Some offices that hire part time associates never bother to credential the associate, and simply submit all billings under the owners provider ID number. Technically this is not legal but it is very common in all health disciplines.

Other offces that are very large (usually HMO or academic type settings) credential the office, not the individual providers. The entity has a group contract for its doctors meaning that each doctor that works at that office is de facto credentialed just by virtue of the fact that they work at the office. However, once they leave that office, the HMO will not even know who they are because they were never credentialed as an individual. This situation is much much more rare and like I said is usually reserved for large insititutional type practices.

Isn't this all so exciting?