Diabetic eye exams get payment help

Following recommendations from the National Committee for Quality Assurance (NCQA) and the Diabetes Quality Improvement Project (DQIP), many of the nation’s managed care organizations (MCOs) are encouraging direct access and offering copayment reimbursement for diabetic eye exams, says the American Optometric Association (AOA).

"MCOs are to be commended for implementing progressive initiatives that encourage direct access for diabetic eye exams by optometrists," states John Mecca, Jr., MD, president of the St. Louis-based AOA. "Oxford Health Plans, Prudential Healthcare, and Wisconsin-based Physicians Plus Insurance Corporation are a sampling of the health plans that have developed direct access programs and other diabetic eye care initiatives, such as co-pay reimbursement to patients. I believe many other MCOs will launch similar programs."

The Oxford, Prudential, and Physician Plus direct access programs allow diabetic patients to visit an optometrist for a dilated eye exam without a referral from a primary care physician. Additionally, Physicians Plus has implemented a co-pay reimbursement program in which the health plan disseminated co-pay coupons to its diabetic patients who had not already received a dilated eye exam in 1998. After receiving the exam, patients have the coupon signed by the eye care professional and then send it back to the HMO for a $10 reimbursement.

"In gatekeeper models, diabetics need a referral from a [primary care physician] for an eye exam. But the NCQA and DQIP reports are having a significant impact on this cumbersome process and are changing the ways that HMOs address diabetic eye care," says Mecca. "Direct access is a welcome change in diabetes management."