Getting Insurance Companies to Pay for Vision Therapy Coverage
Donald Boink, O.D.
I joined the American Optometric Association (AOA) in 1954 and, over the years, went through the offices in my local society in Central New York. The Insurance Committee of the New York State Optometric Association (NYSOA) proved to be a fascinating assignment on my way to the state presidency in 1965, the year the AOA held its convention in New York City. It was a privilege to welcome the delegates from all over the nation to our Empire State. Most likely New York City was chosen to host the AOA convention because the World’s Fair was being held there in Flushing Meadows on Long Island.
My first AOA assignment was the Insurance Committee. The chairman at the time was Sam Mann, O.D. of California. The other committee member was John Davis, O.D. of Kansas, renowned for his extensive autograph collection of famous personages and the fact that he was the coach of the women’s Olympic track team.
AOA’s insurance broker, Daniels and Head, was a small firm from Portsmouth, Ohio whose president was John Lewis. John’s background was electrical engineering, but he was a better salesman, so insurance was an ideal field for him. Up to the time I joined the committee, insurance was a rather mundane matter. That, however, soon changed as rates suddenly escalated by about 30 percent due to radical changes in the health care and insurance industries, brought about, I think, by Federal legislation. We, on the AOA Insurance Committee, began to be subjected to a barrage of complaints from AOA members. It fell to me to respond to the membership about what was going on. From that time on, it was rather routine for insurance rates to increase dramatically.
The AOA insurance program included life and accident and health coverage, with the Continental Insurance Company. The carrier was later shifted to New York Life Insurance Company when some great casualty losses shook Continental severely. The association’s professional liability, or malpractice, insurance was with The Aetna Life and Casualty. Aetna was represented at our meetings with various people, the leader of which was Dr. William Guillette, medical director of the Casualty Division. Attending also was Mr. John Pecorino, Esq., from the legal department, and Mr. Pierce Ennis, of the marketing group. Occasionally, when there was a questionable series of claims, we would meet with Mr. Dean Krebs, manager of the claims department.
I report this to point out that our relationship with the insurance representatives was exceptionally good and we found them very reasonable to deal with. The soundness of that relationship was brought to bear on a number of questionable claims that were causing great turmoil at Aetna.
Dr. Guillette called me on the phone one day and said that their claims manager was in a stew and could the committee help out. Optometrists were stating in their claims that they were “improving children’s ability to read.” There was no language in Aetna’s contracts that covered “reading ability” so those claims were rejected as “not covered”. The ODs were upset because they felt they were being discriminated against. They complained to their state Insurance Commissions which in turn contacted Aetna for an explanation. Dr. Guillette asked if we could explain this situation to the ODs. I said that we would be glad to try and solve the matter. The question seemed to be “how should ODs present their claims in a manner that will compensate them for their services.”
It was evident that ODs were not familiar with insurance contract language. But also, the insurers were not at all sure of optometry’s capabilities.
My suggestion to Dr. Guillette was that we get our two sides together to see where the misunderstandings were and decide how best to correct them. I called Dr. Sam Mann, the chairman of our Insurance Committee and explained the situation and what I felt we should do. Dr. Mann agreed and asked if I would handle the details since I was familiar with the matter. It was decided that we would meet in the AOA office.
The initial conversation at the meeting indicated that we were going to get into a chaotic sort of charge and countercharge exchange. Dr. Carroll Martus, on the AOA “negotiating team,” felt that an offense was the best defense. As chairman of the meeting, I requested that Dr. Guillette state the nature of the problem as he saw it. He began by explaining that a large part of the general problem concerned Aetna’s Major Medical contracts. In these contracts the treatment of medical conditions of the eye were covered. One such condition, for example, was strabismus; another was amblyopia. The customary medical treatment for these conditions was surgery. The claims from ODs that were in dispute were for the optometric treatment of these conditions through vision therapy. This was what concerned him because, in the medical journals he researched, he found that most ophthalmologists had little, if anything, good to say about such treatment.
Two forces had brought Dr. Guillette to seek this confrontation. First, Aetna was being literally bombarded by ODs who were instituting, or threatening to institute, lawsuits against Aetna for failure to pay what they felt were legitimate claims, as well as by state insurance commissioners inquiring about unpaid claims of ODs. The second force was Bill’s own need to resolve this in a forthright and honest manner. His brother was an ophthalmologist and so it is not unreasonable to assume that he felt optometry, quite possibly, was overstepping its boundaries a bit.
The discussion dwelt upon the distinction between the medical model of vision and the optometric model. Dr. George Milkie gave a very apt and lucid explanation of the differences and the rationale to support the argument that the vision therapy claims were legitimate.
It was eventually agreed that more meetings were required and that information and additional questions would be exchanged. The Aetna people brought forth a statement concerning the handling of vision therapy which they wanted the AOA to consider. It became apparent very quickly that there were many changes necessary and that it would be best to allow time for the statement to be considered in some depth. This, too, was readily agreed upon.
This relatively brief meeting may have soon been forgotten by some of the participants; at best not many people were aware of it even occurring. In my estimation, however, it struck a spark that was to ignite into a guiding light for optometry for many years to come and served as the beginning of some of the most meaningful advances that optometry has made in taking its place in the mainstream of health care.
Further discussions, and Dr. Guillette’s willingness to read optometric literature, finally convinced him that perhaps optometric procedures did have some validity. To satisfy the requirements of the Major Medical contracts a list of conditions that were amenable to vision therapy was drawn up. Certain criteria were established by which the efficacy of treatment could be evaluated. Time periods and/or numbers of training sessions were set as progress report checkpoints. This all culminated in a set of “guidelines” from which both the Aetna Claims Department and ODs could work and understand a common language.
The significance of the recognition by one of the world’s largest insurance carriers that optometric vision therapy was effective in ameliorating many conditions of the human visual system seems to me a great milestone in optometry’s advance.
Armed with these credentials and the self confidence engendered by the experience of the successful negotiation, I asked the AOA Board of Trustees for permission to visit several major insurance carriers and try to get them to accept the same guidelines for their Major Medical plans. They agreed. Through the enthusiastic support of Al Katz, AOA Controller, who went along on most of these “missionary” ventures, we covered a significant part of the insurance industry.
Being able to say, “These are the ‘guidelines’ we worked out with Aetna”, seemed to have a magical effect in most instances. We were fascinated by the manner in which powerful insurance executives accepted our message as a welcome and unexpected gift. The guidelines on vision therapy were readily looked at since all of the carriers had major medical contracts for which the guides were applicable.
It was time and money well spent since it returned those dollars many times in claims payments to optometrists over the years.