Coping with changes in an extremely dynamic practice environment is the major challenge ophthalmology practices currently face. An important component of running an efficient practice is providing excellent patient-wellness care beyond in-clinic visits.
At the core of patient-wellness care is education and counseling on eye disease. The opportunity comprehensive practices must consider is whether to depend on optometric/primary-care physician referrals to grow their practices or to take a proactive route to capturing the wellness care needed to supplement the medical practice.
Reimbursement for wellness eye care has created a new model for ophthalmology practices. Practice managers have the unique opportunity to generate new revenue sources for tomorrow’s changing ophthalmology landscape.
How practice managers and ophthalmologists are deciding to handle wellness care is changing the dynamics of ophthalmology practices across the country. In fact, if your practice is not embracing wellness care, you are likely not capturing your share of new patients seeking eye care. Even more important, your current patient base may shrink as your patients look to other eye-care providers who understand how wellness eye care is paid.
Why You Should Consider Participating in Wellness Care
Because most medical insurance companies have defined a way to reimburse providers for wellness eye care by including a vision-plan benefit in their coverage, the answer is clear. Today, even Medicare replacement/Advantage plans and Medicaid include a vision-plan benefit.
Patients of ophthalmologists who decide not to participate in the many vision plans that are offered in their service area must pay out-of-pocket for services. Human resource departments are educating their employees as to which eye-care providers participate with their vision-plan benefit.
Participating with vision plans gives you an opportunity to work with the human resource departments of the larger employers in your area to gain market share. Often the human resource department decides the benefits of a plan. Most vision plans provide the patient a defined benefit that pays for part or all of a wellness eye-care exam, contact-lens fitting fees, contact lenses and/or glasses. Some wellness programs offer discount plans that are accepted by participating providers. The scope of each patient’s benefit is easy to verify through online authorization.
What Vision-Plan Participation Strategies Will Increase Your Success?
- Define your goals and strategies for vision-plan participation. Be certain that your goals and strategies are designed to:
If you are unsure whether wellness care is a suitable opportunity for your practice, a SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis can help you define what is right for your practice. Be sure your list of threats includes a loss of patients with wellness care needs to other participating eye care providers (ophthalmologists and optometrists).
- Capture new patients;
- Retain your current patient base;
- Provide wellness eye care for patients with a vision-plan benefit; and
- Increase revenue for contact lens fittings, contact lens materials and overall optical revenues.
- Identify vision plans in your area and negotiate with them. Analyze not only the reimbursements the plans provide, but also the number of subscribers each has in your area. In my practice, approximately 37 percent of all visits are wellness visits.
Negotiate with the vision-plan programs to determine the fees they are paying in your area. These rates will not be equal to your comprehensive eye exam fee, but they can be negotiated to a respectable level, given that wellness eye care is less complex than a medical exam.
The requirement for a wellness exam will be clearly defined in the vision-plan agreement the plan provides, and must be reflected in your subsequent staff-training material. Be sure to include contact-lens fitting fees, contact lens materials and optical programs in your negotiations. It’s best to speak with other ophthalmologists or practice managers who have experience in negotiating vision plan contracts before finalizing your provider contracts.
- Understand vision-plan reimbursement. Once your practice is a participating provider in a vision-plan program, review the contract carefully and define how your practice will implement the program and how you will capture and bill for all of the service components. Having a written process is key to implementing a smooth staff-training program.
- Have realistic expectations. The fee for a wellness exam will be less than that for your typical comprehensive eye code. Therefore, you must be realistic when negotiating the plan-participation contract. Do not confuse a wellness eye-care exam with your typical comprehensive medical exam, a follow-up visit or a routine exam. Remember, one of the goals of vision plan participation is to grow your patient base.
- Develop a contact lens program. When you agree to become a participating provider for a vision-plan program, you will find yourself in the contact lens business unless you allow this business to go to a national chain or 1-800-CONTACTS.
Most plans provide a contact lens material allowance. By dispensing contact lenses, you will remain competitive, provide a valued service to your patients and make a profit. When you verify wellness visits online for patients who choose to wear contact lenses, you will receive a contact lens fitting-authorization form and a material-benefit form. In my practice, contact lens sales earn a gross profit of 28 percent.
- Strengthen your optical program. As with contact lenses, your optical program will be an essential component of your wellness-program revenue. Optical must be a profit center. Vision-plan programs expect you to capture the optical prescription that you write for your patients.
Vision-plan beneficiaries who select your practice for wellness eye care are expected to give you all of their wellness eye-care business. A wellness visit fee or a contact-lens fitting fee is only a small part of the revenue you will generate as a wellness-care provider.
In my practice, the average benchmark is $146 gross profit per complete optical prescription from a vision plan. Your optical team must be proactive in anti-reflective, transition and frame-upgrade sales to achieve this average gross profit.
- Capture contact lens and optical prescriptions. Ophthalmology practices have traditionally lagged at capturing contact lens and optical prescriptions. Some ophthalmologists are uneasy with asking their patients to purchase contact lenses or glasses from their optical shop. Practice managers can change that culture.
Vision-plan programs have opened the door for ophthalmology to enter the business of providing total wellness care. A successful method for capturing contact lens and optical prescriptions is to have your tech escort the patient to the optical department, introduce the patient to an optical staff member and pass the chart that includes the prescription to the optical staff. A skilled optical staff person will discuss the contact lens or optical prescription and the vision-plan authorization with the patient.
Not every patient will want to purchase at the time of the visit. Opticians must develop and train their staff to interact effectively with a wide variety of patients. Even a scripted response can be a good training tool.
Remember that most of your contact lens or glasses patients are currently using eyewear products. This is your chance to remind these patients of the benefits your practice offers as a participating provider. If nothing else, a courtesy adjustment to glasses or a free carrying case for contact lenses is an important component of patient care that also sets the stage for a return visit.
Benchmarking Vision-Plan Programs
Some ophthalmology practices may be reluctant to consider participating in a vision plan. Fortunately, there is enough experience among managers of ophthalmology practices that currently participate with various vision-plan programs that you need not go it alone. The most important tip to getting your wellness program successfully up and running is to collaborate with a practice manager who is managing a successful wellness program.
Don’t try to reinvent the wheel. Experienced wellness-program practice managers will provide you with the profitability benchmark of each vision-plan program and, most important, explain how to hit that profitability benchmark. E-Talk, AAOE’s listserv, is an excellent platform for finding other practice managers who participate in vision plans. Vision-plan programs may differ, requiring a different strategy for each.
Developing a wellness eye-care program and becoming a vision-plan participant is not for every practice. You must meet with your practice manager(s) to decide if a wellness program matches your practice culture and the culture of your practitioners. Regardless of your decision, wellness care must be included in your next strategic planning session!
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About the author: This article was previously published in the December 2010 issue of Executive Update. It was written by Gordon Barlow, who has more than 50 years experience in health care management and is a co-practice manager with Laurie Hummel at Augusta Eye Associates PLC, Fishersville, Va.