Progressive Focus©

Progressive Focus© Newsletter


Volume 2, Number 4 Winter, 2001
Helping You Manage the Expectations of Managed Vision Care

In This Issue:

How To End An Unsatisfactory Managed Care Contract

Your rights and responsibilities upon termination


You don't need a weatherman to know which way the wind blows.

Bob Dylan
Subterranean Homesick Blues (1965)

Over the past year or so there has been a sharp increase in the number of optometric discussion board postings expressing strong dissatisfaction with some well known vision plans. Many if not most of these postings are from ODs who've decided to drop or have already dropped one or more of their contracts.

At some point you'll decide that you've also had enough of these plans. Enough of the less-than-acceptable reimbursement. Enough of being told which frames you must display and which labs you must use. Enough of the eligibility hassles and retroactive denials. Enough of the late payments, or downcoded claims paid at less than the correct amounts. Enough of staff left listening to "music-on-hold." Enough, enough, enough.


Who will change old lamps for new?

The Arabian Nights
(A Thousand and One Nights)
The History of Alladin

You've finally come to the difficult but incredibly important conclusion that you don't need access to those patients if seeing them is going to disrupt your practice and cost you money. It's time to drop that managed care contract and move on.

Well, having struggled to make that decision (and having convinced yourself and/or your partners that it's necessary) the actual termination process may not be as simple as you might think. You'll have certain rights, but you'll also have certain responsibilities to patients and to the HMO, PPO, IPA, vision plan, or other entity that holds your provider agreement. (Hereinafter we'll call that entity the "plan.")

Notifying the plan

Your first responsibility is to provide proper, written notice to the plan whose contract you signed. Every provider agreement contains language setting out in days the advance notice you must provide --typically 60 to 90 days. In some cases that 60-90 days can be at any time of your choice. In other cases your opportunity to get out is limited to the 60-90 day window immediately preceding the contract anniversary date.

For some plans getting out is a relatively benign process involving little more than sending the required termination letter to the plan. But for others the process is rather more complicated.

In every case you'll want to work with your practice attorney on the wording of the letter. Termination with-cause and without-cause each need to be handled a bit differently, and you must be certain that nothing in your termination letter puts you at any disadvantage.

I suggest that you have the post office obtain a signature from someone at the plan --an acknowledgment that your letter was delivered. Once you've received that confirmation only then can you proceed to the next step -- notifying your patients.

Did You Know...?

In 2000, 93.3% of ophthalmic providers participated in government plans. That's down from the 97.8% participation in 1999. Those participating in private plans dropped more significantly in 2000 -- to 82.9% from 92.7% in 1999. Participation in both government and private plans dropped precipitously to 76.2% in 2000 from 90.4% in 1999.

Average exam reimbursement for 2000 fell to $43.22 from $49.38 in 1999.

20/20 Managed Vision Care
Marketpulse 2001

Telling your patients the news

You do need to notify your patients that you'll no longer be a provider under that plan. What can you say? What can't you say?

First, check your provider agreement to see if it contains anything stating that the plan shall make all announcements to patients concerning provider terminations. Is there anything in the agreement prohibiting you from communicating the news to your patients or limiting what you're allowed to tell them?

Obviously you want to encourage those patients to stay with your practice on a non-participating basis, or switch to another plan in which you are a participant. But a payer is always concerned that former providers will try to convince patients to drop the plan, and some will put language in the contract to prevent any communications that might be perceived as "enticing" patients to switch. Your attorney can help with the proper wording for your letter.

You certainly want to do whatever you can to let your patients know that after the termination date you would like to continue as their optometrist of choice. If you are free to inform your patients in a particular vision plan then send each of them a letter. State that you've reluctantly decided that you cannot continue to provide care for that entity, and invite your patients to stay with the practice.

But think carefully about how much you want to tell the patients about why you've dropped the plan. This is very important in the context of any letter AND in anything said to a patient in person or on the phone!

You don't want to be perceived as "bailing out" on the patients. But if there were administrative or quality of care issues that made it difficult for you to provide the level or quality or timeliness of care you felt was in the patients' best interests, then that might be something you would choose to state. It's legitimate and concerned, not self-serving.

Everyone in the office must be on the same page here. Staff must know what they can and cannot say. You might consider holding a staff meeting -- a training session -- so that everyone understands the issues and can communicate a uniform message to the patients. Your attorney should be able to advise here. (And it may be wise to write a script.)

The key in all of this is to empower your staff. Get them involved. Never leave them wondering, unsure, or confused.


We must dare to think "unthinkable" thoughts. We must learn to explore all options and possibilities that confront us in a complex and rapidly changing world. We must learn to welcome and not to fear voices of dissent. We must dare to think about "unthinkable things" because when things become unthinkable, thinking stops and action becomes mindless.

James William Fullbright
The Arrogance of Power (1967)

The end is not always the end

OK, so you've sent the registered letter and the termination date passes. You breathe a sigh of relief. Free at last, free at last!

Well, maybe not quite yet.

The day a managed care contract terminates does not automatically end your responsibility to the patients from that plan. And it probably does not end your obligations to the terms set out in that provider agreement.

HMO agreements and some vision plan agreements contain language requiring the provider to continue care to patients undergoing active treatment at the time of termination until one of three things happens: (1) the payer can arrange for another provider to take over care and transfer the patient to him/her or, (2) until the current course of treatment is completed or, (3) the patient loses eligibility.

Now, in the patient's best interests that's reasonable, and your provider agreement should state that you'll be paid at the contracted rates for any such "carry-over" care. So as a threshold matter there's nothing fundamentally wrong here.

However, there can be a very dark side to obligatory extension, particularly if you're providing any medical eye care involving repeated patient visits. Let's look farther.

Sorry, Doctor. You're not getting away that easily. (And, by the way, how would you like to work for free?)

The patient's best interests not withstanding, if you have signed a provider agreement with terms similar to those immediately following -- from an actual eye care agreement --you may be trapped in a financially disastrous situation. (Note: I've condensed the paragraph by removing convoluted "legalese" and leaving only the essential wording.)

Article 15: Term And Termination

15.5 Continuation. the termination of this Agreement ... the plan at its option may extend this Agreement ... by giving written notice to Provider of the extension ... until the earliest to occur of (1) the termination of such Payer Agreements, or (2) the date which is twelve (12) months from and after the date of the notice, and Provider shall continue to provide Covered Services ... during the extension term of this Agreement regardless of whether the plan can meet its financial obligations to pay Provider for such services...

Now this is a truly extraordinary contractual nightmare. It says that the plan can obligate you to provide care for up to one year after the termination date, and that you agree to provide that care even if there is no prospect that you'll be paid.

And this extension is not limited to those patients under active care at the time of termination. It's an open-ended, black hole. Incredible! (Note: this is a classic example of why you should have every provider agreement reviewed by qualified advisors prior to signature.)

Collecting for services rendered

Once you've sent notice to the plan it will be in no rush to pay any claims in the 60 or 90 day period prior to your departure. And once you've terminated it certainly won't rush to pay any outstanding claims. So it will be essential that you closely monitor your claims and accounts receivable.

I would suggest that a day or two after the termination effective date you send the plan a complete list of all outstanding claims for services rendered to that point. Include the usual information: patient name, I.D.#, service description, date of service, authorization number (if any), reimbursement due, etc. etc.

Make the letter a friendly itemization of what you've done, and let the plan know that the purpose of your letter is to facilitate a timely and accurate processing of all submitted but currently unpaid claims. In actuality you're letting the plan know that you expect to be paid for every one of these claims, and you expect to be paid per your state's prompt payment (claims settlement) law. As of the Fall 2001 all but two states have some sort of law on the books mandating payment terms.


A master link page to every state's Department of Insurance. Here's where to start when searching for information on your state's prompt payment law.

Protecting and/or transferring medical records

It's essential to check the provider agreement to determine your responsibilities regarding the transfer of medical records. Hopefully you're not financially liable to copy and transfer every record for each of the plan's patients. That could be costly in staff time and copying/mailing costs.

If the provider agreement does not specify that you are responsible for all costs, and if the plan wants the records, and assuming it has the legal right to them, then let it pay for the copying and shipping costs. Do NOT let plan staff come into your office to do this (way too disruptive). Offer to have your staff do it but insist that the plan picks up reasonable costs for your staff time, materials, and shipping.

Remember also to check with your attorney regarding the practice's responsibility to maintain and protect original patient records. State law will require that you secure those documents for a certain amount of time.

And you must also ascertain the plan's rights to the records. Just because a third party payer may demand the records does not automatically give it the right to them.

If every patient has not authorized transfer (perhaps in a document signed when they first enrolled in the plan) then maybe the plan can't have them. Obviously you will transfer any records upon individual, written authorization by a patient. And you're probably required to supply records as part of an audit or upon subpoena. Check with your attorney.

In any case, watch out for potentially problematic, open-ended provisions such as these from another eye care provider agreement.

Books and Records

Provider agrees to cooperate in connection with any transfers of Participants' medical records required when Provider ceases rendering services to a Participant whether during the term of this Agreement or after termination of this Agreement. Provider agrees to provide copies of such records at no charge.

Education is what you get when you read the fine print.

Experience is what you get when you don't.

Has your practice started down the road toward HIPAA compliance? Be sure to see the next issue of Progressive Focus© for tips (and also news to help you manage the expectations of managed vision care)

These materials are intended to provide useful information about the subject matter covered. The author believes that the information is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation of the materials are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any type are disclaimed.

The materials are not intended as legal advice, nor is the author engaged in rendering legal services. The materials are not intended as a replacement for individual legal or professional advice. Information contained herein is presented only for illustrative purposes, and it should not be used to establish any fees or fee schedules, nor is it intended and it should not be construed as encouraging any user of the materials to take any actions that would violate any state or federal antitrust laws, tax laws, or Medicare or Medicaid laws.

Copyright © 2003-2007, Gil Weber, MBA. No part of this newsletter may be reproduced or distributed in any form whatsoever without the author’s prior written authorization.

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