By CLARENCE H. RUSSELL, III, OD
AND CHARLES B. SLONIM, MD
Tampa, Fla.

Rather than surrender to inequitable payment policies that punish the practitioners who fit the small percentage of patients who require medically necessary contact lenses, we decided to take third-party insurers out of the reimbursement loop. For example, we dont submit aphakic or keratoconus contact lens fits to insurance companies for reimbursement. Our office uses the appropriate non-covered service CPT contact lens fitting and replacement codes. Of course, we notified in writing all of our contact lens patients that the financial burden for fitting fees and replacement lenses now lie solely on them. Here are some examples that led us to this decision.

Aphakic lenses. Using Medicare CPT code 92316 to bill for the appropriate fitting procedure at the level of service required along with the cost of the lenses would leave you with a net loss. Medicare made the situation worse for our non-aphakic patients by no longer covering many other medically necessary contact lens fittings. Both procedural codes 92310 and 92314* are non-covered services.

Keratoconus lenses. Even if the insurance company agrees to pay for these lenses most wont unless ocular surgery was performed it wont differentiate between the cost of a simple spherical RGP lens and one specifically made for the keratoconic patient. Similarly, the insurer may not differentiate between the complexities of a keratoconus lens fit and a simple spherical lens. In either case, we lose.

Bandage Lenses Granted Immunity Thanks to disposable lenses, patients no longer have to pay for such bandage lenses as Plano T, Plano U and Plano O (Bausch & Lomb), which ranged in price from $35 to $50 per lens. For the same therapeutic (bandage) effects, virtually all of the available disposable lenses will successfully treat the same conditions for a remarkably reduced cost with the advantage of frequent lens replacement.

Prosthetic lenses. Discolored, misshaped or absent pupils, ocular albinism and color vision deficiencies are a few examples where custom-tinted and custom-designed contact lenses are medically necessary. These custom-made lenses typically carry with them premium prices. Tell the patient what you expect the cost of fitting and replacing such lenses to be. Most of these lenses have a non-return, non-refund policy. The responsibility for obtaining reimbursement from the insurance company should rest solely on the patient. You should expect the patient to pay for these lenses in full prior to placing an order.

Therapeutic lenses. There are some ocular diseases and conditions that require the fitting of contact lenses as either a temporary or a permanent treatment for that condition. Set your fitting fees and lens costs at a higher level for these services as a result of the complex nature of the conditions for which they are being used.

Practically speaking

With the advent of managed care networks and the decline of Medicare reimbursements, the number of conditions for which a contact lens is deemed medically necessary is now limited to only a few. Still, that doesnt mean we have to put profit margins above appropriate care.

Dr. Russell (crussel@tampabay.rr.com) is in private practice, specializing in contact lenses, and is a clinical investigator for contact lens manufacturers. Dr. Slonim (cslonim@tampabay.rr.com) specializes in ophthalmic plastic and reconstructive surgery, as well as contact lenses.