New Texas state laws that help protect practices from vision plan abuses.
By Laurie Sorrenson, OD, FAAO
Sept. 6, 2023
Three new laws have been enacted in Texas to provide much-needed assistance for optometrists navigating vision plans and medical insurance plans.*
- Prohibit vision plans from using extrapolation as a method to complete an audit. This provision does not apply to medical plans. (applies to new contracts entered into or renewed after Jan. 1, 2024)
- Prohibits vision plans from requiring an OD to provide a covered product or service at a financial loss. (applies to new contracts entered into or renewed after Jan. 1, 2024)
- Prohibits improper charge-backs to reimbursements when the vision plan is not supplying the materials (cost of goods) for a patient. (applies to new contracts entered into or renewed after Jan. 1, 2024)
- Requires plans to provide direct, immediate, electronic access to complete in-network and out-of-network plan benefits to the patient and the OD. (Effective Sept. 1, 2023, although it will probably take the plans longer to set this up realistically)
- Prohibits plans from requiring unneeded and unrelated patient information to file a claim or receive reimbursement for a wellness eye exam, including glasses/contact lens prescriptions, unique anatomical measurements like PD, or facial photographs. (Effective Sept. 1, 2023)
- Prohibits plans from calling services and products as “covered” when zero reimbursement of the service or product comes from the plan to the OD. (applies to new contracts entered into or renewed after Jan. 1, 2024)
- Prohibits plans from the identifying and “tiering” of in-network ODs based on discounts on non-covered services, amounts spent on products, or brands or sources of products utilized by the OD. (Some parties, including some of the vision plans, are suing Texas declaring this as unconstitutional based on “freedom of speech” and “equal protection under the law”)
- Prohibits plans from steering patients toward any particular in-network OD, any retail location owned by or affiliated with the plan, or any internet site or virtual provider owned by or affiliated with the plan. (This provision is also under question from the lawsuit)
- Requires plans to accept standardized claim submission forms and processes, and reimburse doctors via electronic funds. (Effective Sept 1 2023, but very doubtful it will be ready on time. Could still possibly require the provider to use a portal)
- Prohibits plans from calling services and products “covered” when the reimbursement amount to the OD is considered “deminimus” in nature. De minimis means of nominal or very small value. (applies to new contracts entered into or renewed after January 1, 2024)
- Prohibits plans from using or offering reimbursement rates that are different from another OD based on the OD’s particular practice and business decisions, such as what lab they choose to use or what products they choose for a patient. (applies to new contracts entered into or renewed after Jan. 1, 2024)
- Requires plans to give 90-day notice to any provider contract changes. (Effective Sept. 1, 2023)
- Prohibits plans from requiring that an OD receive reimbursement through a virtual credit card. (Effective Sept. 1, 2023)
- Prohibits plans from requiring an OD to use any particular EHR. (Effective Sept. 1, 2023)
- Prohibits plans from requiring an OD to use any particular clearinghouse or claim-filing service. (Effective Sept. 1, 2023, but unlikely will be ready in time. A contract can still require a provider to use a portal)
- Requires that the provisions of the bill are to be enforced by the Texas Insurance Commissioner (Effective Sept 1., 2023)
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Those provisions were all in one law. The other two laws passed were:
1) Transparency – requiring any company providing services to an OD to register with the state. That means the Texas Optometry Board and the state of Texas will know who owns a company like a private equity-backed company, an insurance company, or a company that provides business services, and will also know who works for those companies.
2) If a vision plan does Coordination of Benefits, optometrists can file the same day and not have to wait for a rejection.
I believe these new laws will help to create a fairer, more equitable environment for optometrists while also making the doctor-patient relationship a priority.
Kudos to the Texas Optometric Association!
*Unless noted, provisions apply to all managed care plans, including vision plans and medical insurance plans.