Increasing Reimbursement Using Claims Data

When you think of your health, what do you think of? Is it fitness, weight, mental aspects, or all of the above? You wouldn’t be wrong if you said “yes” to any of these, but would you ever think of your visual health? It’s easy to take something for granted, especially when it is such an inherent feature of everyday life, for most. Studies and surveys have shown that nearly everyone agrees that having healthy vision is important, but only half routinely get eye exams on an annual basis. This could be due to a number of factors including lack of understanding of the importance of an annual exam, inability to pay for the services, or lack of access to a provider.

The Colorado Optometric Association (COA) is a voluntary membership organization with over 600 Colorado Doctors of Optometry. Founded in 1892, is it one of the oldest organizations in Colorado, and it supports not only optometric providers, but also the patients they serve. By sponsoring education programs for providers, advocating for programs and laws that represent the patients best interests, and providing information to assist providers, the COA continually strives to expand on the resources necessary to deliver high quality and accessible care.

COA received data from the Colorado All Payer Claims Database in 2013, and was one of the first requestors to receive a non-public analysis. At the time, Colorado Medicaid vision codes had not been reviewed in over 40 years, Medicaid was reimbursing Optometrists at 19% of what Medicare pays, forcing many providers to halt their services for Medicaid patients due to the inability to cover their costs. Even if they did accept Medicaid patients, many providers had to restrict the number of patients they saw for the same reason. With the expansion of Medicaid to 133% of poverty level, the COA wanted to calculate how a modest increase in reimbursement would impact the overall Medicaid budget in an effort to expand access to providers, especially in rural Colorado.

Using data from the CO APCD, the COA was able to make their case to Medicaid that the lack of participating vision care providers was associated with low reimbursement rates. As a result, a recommendation was made to the Governor’s Office of State Planning and Budget to increase the reimbursement rates for certain vision codes. These increased rates became effective July 1, 2014 and the number of participating vision care providers has increased, especially in underserved areas of the state.