Choosing a vision care provider; cost and plan design are among the factors to consider when selecting a vision care plan – Special Report – includes distinction between optometrists and ophthalmologists

Choosing a vision care provider; cost and plan design are among the factors to consider when selecting a vision care plan – Special Report – includes distinction between optometrists and ophthalmologists – illustration

Cynthia K. Walker

Choosing a vision care provider

Cost and plan design are among the factors to consider when selecting a vision care plan.

If you decide that a vision care plan might be worth further consideration, how do you choose a provider that will best suit your needs and your company’s philosophy about what such a benefit should include?

Vision care plans are designed to cover those expenses not normally covered under traditional health insurance plans. But the vision benefit can be managed in much the same way as traditional health benefits. Most vision plans can be customized to your particular needs and budget.

Vision care plans are often established through major commercial insurance carriers, such as MetLife, CIGNA, and Travelers. HMOs and PPOs such as Health-Net, PARTNERS and Southern Health Services often supply the vision benefit automatically as part of their basic health plans.

“Vision care has become so popular, both with plan sponsors and with our HMO competitors,” says Rick Barrett, director of sales and marketing, PARTNERS Health Plan-Houston, “that for us vision is no longer a rider or option; it’s an integral part of our basic plan offerings.”

Traditional indemnity is still another way to supply the vision benefit, but typically it is not the most cost effective. Often, indemnity plans pay the usual and customary rates as determined by the carrier, which may be quite expensive.

A scheduled plan is more popular with employers and also more cost effective because providers agree to accept the fee determined by the schedule of benefits as payment in full.

Plan administration

Vision care plans all have different ways of determining eligibility. Pearle uses a verification system in which the provider determines the patient’s eligibility status over a touch-tone phone. Pearle, rather than the provider, is then responsible for all administrative chores. “That goes a long way toward helping the provider care about the patient rather than caring about the administrative process,” says Peter Barnett, vice president of the managed vision care division of Pearle, Inc.

“Compared to some benefits,” says Barrett of PARTNERS, “administering a vision care program is a breeze.

“The way we’ve set it up with our provider network, neither the employer sponsoring the benefit, nor the employee using the benefit, has any administrative tasks. The employee just shows his card to the provider, and pays whatever small copay is required. There are no claims to fill out, nothing the employer must do or send in. Record keeping is computerized, which means that utilization data are captured and made easily retrievable.”

Where savings come from

Major service networks are able to provide customers with savings because they supply providers with volume. In return for provider discounts, the service networks arrange to steer large numbers of plan enrollees to participating providers. Increased customer counts make providers eager to join the service networks.

Determining company desires

It’s important to know what the firm wants to provide and is willing to spend for the vision benefit. “The question becomes how much money you have and what you want to accomplish with it,” says Pearle’s Peter Barnett. He encourages employers to consider a broad range of vision benefit options.

When it comes down to choosing both plan type and who will provide the services for the vision care benefit, there are some important questions to keep in mind:

* Does the plan have a large number of providers in your region? It doesn’t do employees much good to have a vision program if they don’t have easy access to providers. And yet, while a vision care plan must have a sufficiency of providers, in order to guarantee prompt service, a network with too many providers may be unwieldy to manage and too large to administer. If a network signs up providers indiscriminately, it may become difficult to guarantee quality and consistency of care.

* Is the plan provider easy to work with? How does it handle customer complaints? Customer satisfaction is what makes or breaks any insurance program. Find out what types of customer service the company offers. For example, what sort of product guarantees are available? Some plans have free replacement policies if glasses or contacts are broken, or are improperly made, or if the prescription is inaccurate. It’s also important to find out how the plans deal with complaints. Most complaints are due to communications problems, says Barnett. Company representatives should usually be able to resolve these types of complaints within 24 to 48 hours.

* Does the provider set a standard of care for all who participate in the network? Find out if the company has an established standard of care as part of its contractual arrangement with providers; and also whether it has the capability of monitoring compliance and conformity with those standards. Says Pearle’s Barnett: “A peer review panel sets standards for our providers so that any enrollee who walks in under our auspices is going to receive the same standard of care.” Such standards include:

* quality assurance, which involves both peer review and provider audits; * utilization review; * management information reporting capability, which involves supplying the vision benefit sponsor with data sufficient to evaluate the plan, plus employee utilization and employee satisfaction data; and * administrative capability, which entails operating the program smoothly, solving problems, and making certain that service levels are consistent no matter where plan sponsors may happen to have worksites.

* Is there a quality control system? Does the company follow up on plan enrollees to assure their visit was successful? Some providers require end-of-month reports from all of its doctors and randomly send questionnaires to plan enrollees to solicit their comments regarding the level of service received.

Pearle frequently sends “mystery shoppers” with known visual defects to its outlets to verify that its providers are performing up to expected levels.

Before signing up with any provider, find out what special programs it has to ensure that enrollees will receive high quality vision services.

* How efficiently does the plan handle claims? How are the providers paid? Some plans require that claims be filed. In those cases, it’s important to know how efficient the claims processor is. Corporate sponsors should find out if the vision care vendor processes its own claims or contracts for the service. Sponsors should also ask to talk with current clients of the vendors.

“The biggest problem with any plan is service,” adds Gary Yeaw, Allied-Signal’s corporate director of group insurance. “If bills aren’t getting paid on time, it’s important to find out why.”

Finally, when instituting a vision care program, the Employee Benefit Research Institute advises inclusion of a program to “increase employee awareness of vision care and the plan [and provide] effective communication among all involved parties: the employee, the employer, and the provider.”

COPYRIGHT 1990 A Thomson Healthcare Company

COPYRIGHT 2004 Gale Group