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By Rhiannon Riches

Disgruntled optometrists have been vocal after receiving a letter from health fund Medibank Private, advising whether they have been approved to continue as a recognised provider.

Optometrists expressed their annoyance at being ‘judged’ on their compliance without being given an opportunity to have input into the process.

Medibank Private notified optometrists in the letter that they were being reviewed and evaluated to confirm that they were adhering to Medibank’s ‘Requirements for Recognised Providers’. The document is available on Medibank Private’s website.

The evaluation includes whether the business location at which the optometrist works complies with Medibank’s requirements.

The letter explained that a small number of providers failed Medibank’s review process and had been notified that their recognised provider status had been suspended.

According to the letter, ‘If provider recognition at a particular business location is suspended, the suspension will remain in place for two years.’

Some optometrists described the letter as a scare tactic while others considered it a necessary means to prevent health fund fraud.

Professional services manager Luke Arundel said that optometrists notified Optometry Australia that they had received the letter in the final weeks of June, before the end of the financial year.

‘Optometry Australia appreciates members being our “eyes on the ground” with these issues. We are monitoring the situation and assisting members where appropriate. There is an avenue for appeal for those providers who received suspension and there is a number of these in progress,’ he said.

Members of Optometry NSW/ACT have been particularly vocal in their reactions when advised that patient benefits had been suspended.

After several failed attempts to obtain specific information about Medibank’s concerns, Optometry NSW/ACT has taken the step of writing to the Private Health Insurance Ombudsman to voice its concern at Medibank’s actions.

Optometry Australia has also made contact with Medibank Private about its review and monitoring process.

Mr Arundel urged members to regularly familiarise themselves with the rules associated with each private health fund, often described as ‘recognised provider requirements’.

The private health insurance sector needs to provide better clarity for optometrists around claiming procedures. Optometry Australia will engage the key players in developing broad, uniform guidelines to assist members,’ Mr Arundel said.

For assistance or questions regarding the outcome of the Medibank Private review, contact Luke Arundel on 03 9668 8560 or l.arundel@optometry.org.au

Medibank responds

Medibank’s media spokesperson Victoria Hanlon said Medibank regularly reviewed its health-care providers to ensure they were delivering services according to Medibank’s Fund Rules, Provider Recognition Criteria and applicable industry standards.

‘So far, we have conducted reviews of providers across the dental, acupuncture, Chinese herbal, remedial massage, optical and podiatry modalities,’ Ms Hanlon said.

‘In a small number of instances, we have found health providers who aren’t following recognised rules and standards. For optical, this can include optical providers supplying members with non-prescription sunglasses and sanctioning private health insurance benefits to be claimed for them.’

‘Our review found behaviours such as optical providers advising members to inform Medibank that they claimed for prescription sunglasses, if asked.

‘We found optical providers selling members cheap “two dollar” glasses with the wrong prescription, then using the remaining private health insurance benefit to sell the member non-prescription sunglasses. The idea was that the optical provider could then prove they had sold prescription glasses, if questioned.

‘Through our review, we also discovered optical providers utilising multiple family benefits to create a credit or discount when the other family member was not present, and we found non-prescription sunglasses being sold and billed as “frames”, with the explanation that prescription lenses would be fitted at another location, which Medibank discovered was not in fact the member’s intent,’ Ms Hanlon said.

She said that as of 7 July, 40 optical providers, working across 57 locations, had had their Medibank or AHM provider recognition suspended. AHM is a subsidiary of Medibank.

‘This equates to 0.5 per cent of our recognised optical providers,’ she said.

‘However it has been typical in the reviews and audits conducted to date that we find only a very small number of providers who intentionally aren’t doing the right thing; the vast majority of our providers are doing the right thing by our members.

‘Where an optical provider is no longer operating from a particular location, we encourage them to contact Medicare and have their provider number closed to prevent misuse of the number. Some optometrists had left practices and claims had been submitted under their provider number without their knowledge,’ Ms Hanlon said.

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