The 3rd Party 12 Visit CI Fiasco


Insurance Cartoon

As if third party coverage for optometric vision therapy services weren’t challenging enough already, there has been a disturbingly growing trend for carriers to deny claims for office-based vision therapy until the patient has tried home based therapy for 12 weeks first.  I blogged about this a couple of years ago.  Where did this idea come from that home-alone therapy prior to office-based therapy can be effective?

If there is a basis for this, it is a twisted application of the CITT study.  In that study, comparisons were made between home-based pencil push-ups (HBPP), home-based computer vergence/accommodative therapy and pencil push-ups (HBCVAT+), office-based vergence/accommodative therapy with home reinforcement (OBVAT), and office-based placebo therapy with home reinforcement (OBPT) as treatments for symptomatic convergence insufficiency (CI).  A successful or improved outcome was found as follows: OBVAT 73%; HBPP 43%; OBPT 35%; and HBCVAT+ 33%.

home-alone-logo

That’s right.  Home Alone therapy doesn’t fare very well.  In fact, it can’t be differentiated from placebo therapy.  Don’t get me wrong – placebo therapy can be very powerful.  The problem is that third party carriers who adopt this arbitrary “12 weeks of home-alone therapy first” are trying to avoid reimbursing for office-based therapy hoping that one- third of their CI claims respond satisfactorily to home-alone therapy.

Cost Sharing

So here’s my advice.  If you or you patient receives a letter from their carrier requesting documentation of the results of 12 weeks of home based training and the results, respond as follows:

Dear Carrier,

I am in receipt of your letter dated X/Y/Z requesting documentation of the results of 12 weeks of home based training and the results.  However, there is no scientific evidence that home based therapy is efficacious for your subscriber’s condition.  In fact, the only randomized clinical trial (CITT) comparing home based training to office based training showed that home based training was no better than placebo therapy.

Since it is not our practice to prescribe therapy that is tantamount to placebo prior to prescribing office-based treatment, your request is not relevant to reimbursement in this case.  Please re-process the claim accordingly, or advise your subscriber that your policy regarding treatment is to require placebo level therapy for any diagnosed condition before reimbursing for other interventions.

Sincerely,

 

3 thoughts on “The 3rd Party 12 Visit CI Fiasco

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s