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So You Want to Start Fitting Medically Necessary Contact Lenses?
There’s a lot to consider before choosing to offer this service. Here’s what you need to know.
Roxanne Achong-Coan, OD, FAAO, FIAOMC, FSLS, FBCLA
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At A Glance
- Educate yourself on all contact lens modalities rather than building your expertise in only one modality.
- Referrals for medically necessary lenses can be obtained from teachers, ophthalmologists, optometrists, and other health care providers.
- Every insurance company has its own criteria for coverage of medically necessary contact lenses.
Adding medically necessary contact lenses to your practice is a rewarding decision, but one that requires careful planning, dedication, and hard work. Before even considering starting this journey, you must already be passionate about this subspecialty, otherwise it will not be a success.
So, what exactly is a medically necessary contact lens? There is no universal definition, but the category includes soft, spherical, and toric lenses, as well as hybrid, rigid gas permeable, and scleral lenses. These lenses are typically used to provide a quality of vision that is better than the patient’s experience with glasses or to treat some type of ocular surface disease. Every insurance company has its own criteria for coverage of medically necessary contact lenses (see Insurance Plan Coverage of Medically Necessary Contact Lenses ). It is important to download the manual for each type of health insurance that you accept or plan to accept and have this information readily accessible.
Before you dive in, be sure to educate yourself on all available contact lens modalities (ie, soft, rigid gas permeable, hybrid, and scleral) rather than building your expertise in only one modality. This way, you can give patients the best recommendations based on their diagnosis and financial situation.
Completing a contact lens residency can give you the opportunity to work and network with educators, students, and researchers in the contact lens space. It will also expose you to many different specialty lens patient cases, including some difficult cases, in a short span of time because of the availability of contact lens diagnostic sets and the technology that is used to aid in lens fitting.
If you are unable to undertake a residency, you can still select a site to practice with an experienced doctor who is willing to mentor you in specialty contact lenses. National meetings such as the American Academy of Optometry, the American Optometric Association, the Global Specialty Lens Symposium, and Vision by Design from the American Academy of Orthokeratology and Myopia Control are excellent places to learn more about specialty lenses. Online education and resources are also available via the Gas Permeable Lens Institute, Woo University, and Scleral Lens Education Society, to name a few options.
Once you have achieved many successful lens fittings, you can then share your cases by writing articles for professional publications. This way, you can become the mentor and give local talks to raise awareness of your services, and, as you gain experience, you can even participate in continuing education meetings. This can be a great practice-builder because many individuals who are researching their ocular conditions may read some of these published articles and seek you out as their eye care provider as a result.
Insurance Plan Coverage of Medically Necessary Contact Lenses
Below are several examples of vision plans that cover medically necessary contact lenses.
Davis Vision — Requires prior authorization and offers benefit coverage for aphakia, aniridia, keratoconus, progressive and pathologic myopia, post-cataract surgery, and irregular astigmatism. 1 Claim must be faxed with supporting documentation.
EyeMed Vision Care — Has five groups of benefit coverage: anisometropia, high ametropia, keratoconus (mild/moderate, and advanced), and no vision improvement when keratoconus is absent. 2 Claims must be faxed.
Spectera — Insurance coverage for medically necessary contact lenses includes keratoconus, aphakia, irregular astigmatism, anisometropia >3.50 D, facial and corneal deformity, corneal opacity, corneal degeneration, corneal ectasia, and VA <20/70 with glasses and >20/70 with contact lenses. 2 Claims must be faxed with supporting documentation.
Vision Service Plan — Has benefit coverage criteria for patients with aphakia, aniridia, keratoconus, nystagmus, corneal transplant, high ametropia (10.00 D) in any meridian, anisometropia 3.00 D, irregular astigmatism, achromatopsia, albinism, pupil abnormalities, polycoria, congenital anisocoria, and hereditary corneal dystrophies. 2 Claims must be filed electronically.
1. Davis Vision. Medically necessary contact lens clinical criteria effective January 1, 2018. Revised October 1, 2017. cvw1.davisvision.com/forms/StaticFiles/English/Davis_MN_Contact_Lens_Clinical_Criteria_2018.pdf. Accessed June 13, 2022.
2. Achong-Coan R. Ensuring compensation when fitting medically necessary contact lenses. Modern Optometry . 2021;1(4):44-51.
GET YOUR TEAM ON BOARD
Staff education is another critical component to mastering medically necessary contact lenses. From the call center to the technicians, to the opticians, to the billing department employees—every team member must be able to identify potential patients who may benefit from these lenses and schedule the appropriate length of time needed for the appointment. Past medical records will help you to efficiently fit contact lenses, as there will be a history of what has and has not been successful.
Regular weekly or monthly meetings are an opportunity to teach staff about the differences between lenses, the data required from instrumentation to achieve a successful fit, the disinfection solutions needed to clean the lenses, the techniques for insertion and removal of different lenses, the saline solutions required to fill the bowl of the lenses before insertion, and the artificial tears that are approved for use with the different contact lenses.
The technology used to aid in contact lens fitting is expensive, but worth the investment. Such technology is used to diagnose ocular disease, evaluate its severity, and check for its progression.
For example, pachymetry measures the thickness of the cornea and should be performed in patients who have progressive corneal diseases such as keratoconus and corneal degenerations. Corneal topography is used to evaluate the shape and height of the cornea, while scleral topography is used to evaluate the shape of the surrounding conjunctiva close to the limbal area. Anterior segment OCT measures the apical clearance of the lens and displays the landing of the lens on the conjunctiva. Specular microscopy can be performed to measure cell count in patients who have had corneal transplants and those with Fuchs dystrophy.
DO YOUR RESEARCH
Selecting one or two labs to work with and speaking with contact lens lab consultants who are familiar with the different lens designs that the manufacturer uses will help you acquire knowledge about these specific lens designs. When choosing a lens manufacturer, it is critical that you consider the questions below:
- What is the cost of the lens?
- How many lens exchanges are allowed at no charge, and what is the cost of additional lenses if there are no more exchanges left?
- What is the timeframe for achieving a successful fit before there are any additional charges?
- What are the shipping charges to the practice?
- Does the lens for a new order include a starter kit and accessories, such as tools for lens insertion and removal, mirrors, and/or sample saline to fill the bowl of the lens before insertion?
- How long does it take for the lens to be manufactured and shipped to the practice?
- What are the warranty policies for broken lenses and non-wetting lenses?
- What is the cost of a loaner fit set, and what is the timeframe on the loaner kit?
- Do lenses that do not work need to be returned to the manufacturer?
DON’T FORGET ABOUT MARKETING
Once your practice begins to offer medically necessary contact lenses, it would behoove you to establish a budget to increase awareness in the community about this new service. There are two types of marketing, external and internal, and you may choose to employ elements of each.
From the Archives
Want to read more on this topic? Check out these articles on medically necessary contact lenses from past issues of Modern Optometry :
Medical Applications of Contact Lenses
By Micaela Crowley, OD
Ensuring Compensation When Fitting Medically Necessary Contact Lenses
By Roxanne Achong-Coan, OD, FAAO, FIAOMC, FSLS
Get Medical With Your Contact Lens Prescribing
By Melissa Barnett, OD, FAAO, FSLS, FBCLA
This type of marketing includes websites, podcasts, community service meetings, and social media (ie, Facebook, Instagram, TikTok).
This form of marketing includes website blogs, email, text messages, newsletters, reviews, and on-hold messages.
Referrals for medically necessary lenses can be obtained from teachers, ophthalmologists, optometrists, and other health care providers. Follow-up letters should be sent to anyone who provides a referral to update them on the patient’s medical history. These letters will help to build trust with your referees as you continue to successfully fit these patients with medically necessary contact lenses, ultimately spreading awareness of your services.
THE FINISHING TOUCHES
When a patient decides to try medically necessary contact lenses, any costs associated with treatment, lens care products, and the lenses themselves should be calculated and thoroughly explained to them. Have the patient sign a contract, which should include the following details:
- The patient’s medical condition and prognosis
- Insurance coverage for medical and vision and the copay amount
- How to handle extra tests during the examination that are not covered by insurance
- Out-of-pocket expenses (eg, patients may have to purchase supplies for the lenses at the dispense or replacement materials if a starter kit is provided)
- Cost of disinfection systems and solutions needed to wear and maintain the lenses
- Explanation of warranty policy if the lenses become lost or broken
- The importance of keeping scheduled appointments to complete the fit
- Cancellation fees, if applicable
WORTH THE REWARD
Choosing to offer a medically necessary contact lens service requires education, organization, and preparation, as it is a considerable financial investment. However, in my opinion, it is the most rewarding feeling to help patients for whom wearing these lenses is the only way for them to function normally. In fact, patients fit with medically necessary lenses are often very appreciative and many become lifelong loyal patients who, in turn, refer other patients to your practice in the future.
Optometrist and Owner, Coan Eye Care & Optical Boutique, Ocoee, Florida Member, Modern Optometry Editorial Advisory Board [email protected] ; Instagram @coaneyecare Financial disclosure: None
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Configuring Spectera Formulary Contact Lens Allowances
You can configure contact lens coverage allowances for Spectera insurance plans. From the Formulary Contact Lens Allowances window, you can perform the following actions:
- Add contact lens allowance amounts along with the corresponding quantity of disposable and planned replacement boxes allowed. You can add contact lens coverage allowances that apply to all plans or to specific plans.
- Edit the quantity of disposable and planned replacement boxes allowed for an allowance amount.
- Copy contact lens coverage allowances between plans.
- View a history of all changes made to contact lens coverage allowances.
- Generate a PDF report showing contact lens coverage allowances for all plans and individual plans.
- While the following procedures can be used for any insurance carrier, this functionality is intended for setting up formulary contact lens allowances for Spectera insurance plans.
- The contact lens coverage allowances that were previously set up for your company appear in the grid the first time you access the Formulary Contact Lens Allowance window.
This section explains how to set up contact lens coverage allowances.
Topics include the following:
- Open the Company Information window. See To open the Company Information window .
The Company Carrier window opens.
- From the Insurance Carrier drop-down list, select the carrier name your company has set up for Spectera.
The Formulary Contact Lens Allowances window opens.
- Open the Formulary Contact Lens Allowances window. See To open the Formulary Contact Lens Allowances window .
- To search for allowances that apply to a specific plan, select the plan name from the Plan drop-down list. The Plan drop-down list is blank by default and the allowances that appear in the grid apply to all plans.
- To search for allowances that are currently inactive, select No from the Active drop-down list. Yes is selected in the Active drop-down list by default and the allowances that appear in the grid are active. To view both active and inactive allowances, leave the Active drop-down list blank.
- To add an allowance for a specific plan, select the plan name from the Plan drop-down list. If you add an allowance with the Plan drop-down list blank, the allowance applies to all plans.
A second Formulary Contact Lens Allowances window opens.
- Allowance : Enter the allowance amount.
- Allowed Disposable Boxes : Enter the quantity of disposable contact lenses boxes allowed for the allowance amount.
- Allowed Planned Replacement Boxes : Enter the quantity of planned replacement contact lenses boxes allowed for the allowance amount.
- (Optional) To add the allowance as inactive, deselect the Active check box. The Active check box is selected by default.
- Click Save .
- (Optional) Search for the allowance to edit. See To search for contact lens coverage allowances .
- Click Edit in the row for the allowance you want to edit.
- Update the quantity of disposable or planned replacement boxes allowed in the provided fields.
- (Optional) Update the selection in the Active check box. You cannot update or delete allowance amounts. If you no longer need an allowance amount, deselect the Active check box to make it inactive.
- Click Update .
The Copy Formulary Contact Lens Allowances window opens.
- From the Copy From Plan drop-down list, select the plan with the allowances you want to copy. All allowances configured for the selected plan are copied. You cannot select individual allowances to copy to another plan.
- From the Copy To Plan drop-down list, select the plan you want to copy allowances to. If the plans you are copying allowances between have the same allowance amount but different box quantities, the box quantities for the plan you are copying allowances to will be overwritten.
- Click Copy and click OK in the confirmation message window.
The Allowance History window opens and shows all changes made to allowances. The history includes the date and time of the change, the employee that made the change, the carrier associated with the allowance updated, the plan name associated with the allowance update if applicable, and the change made.
The CLAllowancesReport.pdf is exported to your default download folder. The exported PDF report shows the allowance details for all plans and for individual plans. The allowance amounts without a plan name apply to all plans.
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Hey guys, just wondering if anyone's gotten the email from Spectera about their new formulary for antiglare and progressives. Does anyone know exactly what the new formulary is? They're not providing anything until the date it goes into effect, but we have to sign the documents before then otherwise our contract terminates on that day. Anybody have any info? Thanks!
Most of us left "Specterrible" years ago and never looked back. Your post reinforces what a great decision that was- for our office anyway!!!
Originally Posted by Uncle Fester Most of us left "Specterrible" years ago and never looked back. Your post reinforces what a great decision that was- for our office anyway!!! You're not wrong there Fester. My practice back in NC dropped Spectera first of the year because of this change. And we dropped Superior back in 2020 for the same thing. Ultimately not worth it. And I'm having to navigate the VSP stuff with this practice in GA because we're 100% Essilor. Complete minefield lol
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We did get an email with contract and reimbursement rates all together in one 7-page PDF. Now, I can't find the existing reimbursement rates to compare, but probably safe to say these are worse. The new patient cost formularies will only be available on the site May 1. The only interesting thing is now providers use their own frame instead of the lab supplying them, but the reimbursement claims to be based on your retail fees. This would be good news, but I *know* there's a nasty caveat buried in their somewhere. If not Spectera will figure one out quick first time I bill them a $1000 frame.
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