USE CASE: Increasing Reimbursement Using Claims Data


The Colorado Optometric Association (COA) is a voluntary membership organization with over 600 providers participating. Founded in 1892, the COA is committed to helping their member provide the highest standard of professional care to their patients by sponsoring continuing education programs for doctors, advocating in local and state governments for programs and laws that represent patients’ best interests, and providing information to assist doctors practicing in a variety of clinical settings.

Project Summary: When the COA requested CO APCD data, Colorado Medicaid Vision Codes had not been reviewed in over 40 years. In many cases, Medicare reimbursed Optometrists at 19% of what Medicare pays; this forced many Doctors of Optometry to stop taking Medicaid patients. Twenty-six dollars for a comprehensive eye exam was not feasible for O.D.’s to cover their chair costs. Those Doctors of Optometry who did accept Medicaid severely restricted the number of patients they saw for this same reason. With the expansion of Medicaid to 133% of poverty level, COA wanted to be able to calculate how a modest increase would impact the overall budget versus the number of O.D’s available, especially in rural Colorado, to service patients.

Benefit to Colorado: The COA presented to the Department of Health Care Policy and Financing regarding the incredibly low Medicaid reimbursement rates. They showed that the lack of participating vision care providers is due to their inability to recover the minimum chair cost (price per patient per hour).

Based on data presented, the Department made a recommendation to the Governor’s Office of State Planning and Budget to increase the reimbursement rates for certain vision codes. This budget increase was then recommended to the State Legislature through the Joint Budget Committee where it was approved by both the House and Senate. 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.