MANAGED CARE UPDATE |
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E-Claims and Diabetic Care: Changed Traffic Patterns AheadRandolph Brooks, O.D., F.A.A.O. If you want to get an argument going at a local senior citizens' center, just ask the seniors what they think about making changes to Social Security and Medicare. Then take a couple steps back; you won't have to wait long for a response. You can expect the same type of ruckus if you ask colleagues at a local society meeting what they think about managed care, or where they think health care is headed, or should be headed. For most of us, the continued health of our practices hinges on how well we understand managed care today and its future trends. Here's a glimpse at some key trends. E-Claims Standards As we wait-and wait-for Congress to enact a patient bill of rights, provisions of another managed-care reform act are taking effect. The Health Insurance Portability and Accountability Act (HIPAA) of 1996-also called the Kennedy-Kassebaum bill for co-sponsors Sens. Ted Kennedy (D-Mass.) and Nancy Kassebaum (R-Kan.)-requires that the Department of Health and Human Services develop standard formats for health-insurance claims. This would include standard data content and formats for submitting electronic claims. The law would also set up unique identification numbers for patients, employers, health plans and providers. We O.D.s should welcome these numbers because many of us cannot get Drug Enforcement Agency numbers, which may explain why studies have underestimated our drug prescribing patterns. Expect the Internet to play a big role in the way health plans comply with HIPAA electronic standards. Vision Service Plan (www.vsp.com) and others already use the Internet for authorization and claims filing. In April, VSP spun off a separate for-profit company called Eyefinity to serve as the destination for all VSP electronic claims. Davis Vision also has its own Web site (www.davisvision.com) through which members can check their eligibility for services and providers can receive authorization for member services. If you're not already filing third-party claims and verifying patient eligibility over the Internet, you probably will be soon. Diabetic Eye Care The National Committee for Quality Assurance (www.ncqa.org), which accredits health plans, released its State of Managed Care Quality 2000 report in September. The bad news: Some 24,000 people will go blind from diabetes this year. The good news, however, is that the number of diabetic patients who received annual dilated retinal exams went up from 41.4% in 1998 to 45.3% of patients in 1999. NCQA-accredited plans tended to do better overall than non-accredited plans, in which 44% of diabetic patients received annual eye exams. There are also regional differences. For example, eye examinations for diabetics increased the most between 1998 and 1999 in the Mountain states, with 8.7% of diabetic patients receiving dilated fundus examinations. Health plans will continue to make eye care more available, especially for the diabetic patients. Many plans already have stopped requiring referrals and co-pays for these patients to seek annual eye care. This allows us to provide the full range of eye care services, reducing morbidity and complications from both eye disease as well as ocular manifestations of systemic disease. What's next? Many of us probably dream that one day our patients will carry smart cards that allow us to get instant eligibility information and electronically transfer funds into our accounts so that we actually get paid for services provided by the time the patient leaves the office. Of course, by the time that happens, I may well be one of those seniors raising a ruckus at the local center. top
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| © Review of Optometry OnLine November 15, 2000 |
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