# Optical Forums > General Optics and Eyecare Discussion Forum >  Managed Care - VSP / EyeMed

## NSB1981

I'm a benefits administrator for a large regional employer (+25,000 employees) and I'm researching the difference in provider reimbursements between EyeMed & VSP. Specifically, we're interested in determining which carrier has more favorable reimbursement terms for providers (both lens and frame allowances) and offers the greatest flexibility to participants. Any info or feedback would be very appreciated.

1. For frame purchases that exceed the network frame allowance, does the network agreement allow you to balance bill the ppt up to U&C? Does the network limit the out of pocket cost or require a discount to the ppt and if so, what is the limit/discount?

2. Which carrier has better provider discounts for the carrier's proprietary brand frames? (Marchon / Luxxotica)

3. What is the review/approval process for medically necessary contacts?

Thanks in advance for your help!

----------


## doctorjmjb

VSP generally is better.  Reimbursement is better, clarity of benefits, and most important *customer service*.  The only advantage with Eyemed is that they allow the most freedom with lab work (but, VSP is getting better all the time.)

----------


## shannon

I agree, if we are only comparing the two, VSP is the better choice.  VSP has a very easy to use website for providers and their customer service is second to none.  I have had only one claim that I was not able to work out with them...and to be honest, it was our fault anyway.  Their EOB's are clear, they state what the patient should have paid, what they will pay to us, and what the lab payout with be.  Eyemed is easy to file but favors Luxottica products as it is a part of Luxottica. Both plans USUALLY allow the patient to choose between glasses or contacts and they will give an amount that they will pay towards a contact lens exam and the contacts.  There are some discount plans that will probably be very different. Plans between the two vary quite a bit, so your other questions may be a little more difficult to give an accurate answer to, but someone on here is bound to be able to shed some light on them.

----------


## Jubilee

It depends...

Both companies have their pros and cons, and depending upon the provider, one will be more favorable than another. Within each company, there are several "levels" of plans that offer both better coverage for the patient/employee and better reimbursement for the provider.

VSP is geared towards the independent practicioner. While some plans are able to go to select chains, most of the action is seen within the private practice arena. They select a group of labs to be affiliated with, and the provider *must* get the covered patient's glasses from there. The frame coverage is presented in both wholesale and retail value. So if the frame is $180 and the allowance is $150, the patient may or may not have to pay based upon the wholesale value. So you can think of this as a "controlled mark up" if you will. Most lenses have set pricing from VSP. They determined what "copays" for material, coatings, lens style, etc is paid, and from that part goes to VSP as a service fee (to cover the extra cost of the lenses/processes) and part goes to the provider for the "upgrade."  

EyeMed is geared toward "retailers." It is owned by the same parent company as LensCrafters, Pearle (corporate owned), SEARS Optical, and the opticals in BJ's. So of course they want a plan that is able to work well within their own concepts. You are able to use any lab you want, or manufacture the materials themselves. All their allowances are based upon Retail only. (Cause of course usually they have more buying power so pay less for the same products as most private docs.) While some of the copays are spelled out as $X dollars, many are formula driven. Such as take your U&C X 80% - 119 = COPAY. Most plans reimburse the facility more $$ than VSP, but they also have to pay for cost of goods out of that reimbursement.

So for most facilities, which one is better is driven more by how well you control your cost of goods. In the last practice I worked in, if we used the same lab, and did everything the same with an EYEMED order as we did a VSP order, we would end up making virtually no profit. Once we started to do our own edging, and reigned in our COGs, we were able to provide same quality with a faster turn around.. with a higher profit for us. 

 Eyemed can be used in more *types* of places. This means that many optician owned shops can take the insurance for materials, and not just the independent doc who works with them. However, EyeMed is also owned by a parent company who is a main competitor of sorts. So some prefer not to work with them period. VSP won't allow optician owned shops participate.. so that knocks out a lot of great places to get good, quality eyewear.


Now to your questions:

1) Both plans usually will have a rider that states the patient will receive 20% off the difference. So is allowance is $150, and frame is $200,  $200-$150=$50 less 20% = $40 out of pocket for patient. I have seen some that go a bit higher, to 25-30%, but most are 20%.

2) Again, this is based upon the provider. Most discounts are based upon volume, with some by promotions. If you do a lot of business with either company's FRAMES, then you will receive a discount for their lines. Note, many of those are line specific. So while the office might get a 20% disc off of core product (basic/non designer lines) many of the name brands are going to be much less (8-10%). Some lines have set pricing, no discounts. There is a fair number of providers that refuse to carry Lux brands due to the "helping the competitor" factor. However there are a fair amount of opticians that won't buy from Marchon since VSP won't allow them to be independent providers. 

3) Both lines have their own criteria, that they outline upfront. Usually it is usually something like +/- 10.00 sph, having a 4 diopter or higher difference in the rx between the eyes (ansiometropia) or having a condition such as keratoconus where they need contacts because glasses can not adequately correct their vision. Usually your doctor will designate the criteria on why you should receive contacts as medically necessary, and submit a special form to get approval. The process is fairly quick (usually less than a week) and if approved, they will cover one year's worth of cls. That could be one pair, or several boxes of disposables based upon the reason and script.

----------


## shannon

Jubilee:

+1 !  I knew someone would explain it well :)  I can barely spell my own name after today.

----------


## optical24/7

I don't mean to sound rude NSB, but as a benefits administrator what do you care about provider reimbursements? You should be looking at costs to your company and employees vs access to providers. VSP only contracts with independent OD's (and a few MD's). Where as EyeMed contracts with independent OD's, MD's, opticians and chains.

----------


## rdcoach5

I think the administrator is looking to give his employees the best choice of eyecare providers. To do that there must be an adequate compensation for the providers to sign on .  For example, our office dropped a lot of Eyemed plans when they mandated a 30 % discount. We don't mark up enough to give a 30 % discount. The chains do play that game and we find that their frames discounted are still more than our regular price. Not to knock the chains but that is not the best eyecare.

----------


## optical24/7

Almost all VSP providers also accept EyeMed vs All EyeMed providers aren't allowed to accept VSP. As example independent opticians can accept EyeMed but are blocked from VSP. (There's some dang good opticians that own their own place.)

As a consumer I would want as much portability of my plan so I could seek out and use the best for each service (Exam and glasses).

----------


## NSB1981

Thanks for the info - it was very helpful. As an employer, claims expense is a major consideration, however we also look into other factors such as network access, out of pocket costs to the participant, customer service metrics etc.

We generally have access to very detailed claims data for our population, such as average claim cost, utilization / type of materials being dispensed. That doesn't always translate to measuring effectiveness. The VCPs often define their claim definitions and eligibility requirements differently which means we're not always comparing apples to apples. Also, the plan is only worthwhile to our ppts if they use it and get value from it. For example, a VCP can offer lower admin fees and show a lower cost per claim, by setting the provider reimbursement at or barely over cost and shifting the difference to the participant out of pocket. 

In turn, that results in the participant being dissatisfied with the plan. On your end, it usually means an unprofitable customer (or one irritated about their out of pocket costs) - ultimately giving you an incentive to leave the network.

Yes, cost is the 800lb gorilla in choosing a vendor, but it can be misleading because it's easy to manipulate discount and retail prices when the VCP and manufacturer are one and the same.

It's been my individual experience that with vision care (like most other things) you get what you pay for... if you want to spend only the $150 or so frame allowance and covered lens options, you can, with the understanding that you'll get what you paid for. What is important is that the participant has a choice - they can choose between a basic product with little OOP expense, or a better product which they'll have to pay out of pocket for but for which the plan still offers value.

----------


## Fezz

Why not just give them a flat amount to use towards eyewear/eyecare?

----------


## Johns

> Thanks for the info - it was very helpful. As an employer, claims expense is a major consideration, however we also look into other factors such as network access, out of pocket costs to the participant, customer service metrics etc.


If access to care it truly a consideration, then Eyemed beats VSP hands down.  VSP,by design, restricts it's panel to only OD owned offices.  That eliminates Ophthalmologists and Opticians right off the bat.  In a few cases, they have been pressured to open panels to a select few chains, but MDs and Opticians are still, for the most part kept out.

Whether it's healthcare, eyecare, or a 401k, my employees want choices.  VSP is VERY limited as to the type of facility they can go to.  Very little choice there.




> ...it can be misleading because it's easy to manipulate discount and retail  prices when the VCP and manufacturer are one and the same.


Bingo.

----------


## Uncle Fester

Having seen Eye Med poach a lot of VSP patients with promises of the same bang for the buck I can't think of one instance where the employee was glad of the change and didn't pay more for the same glasses.

From a customer service point of view VSP also has dependable answers when either administrators or your employees call with questions. We find we must try to process EM claims while the patient is still in the office. On many occasions the printed authorization will dictate prices that are not valid when billed This usually happens when lenses only are involved and instead of the authorizations numbers it turns into a straight 20% discount of usual and customary charges which means if the patient has left the office we have to call them and feel like a used car salesman when we tell them they owe another $xx. This "glitch" in their system has been being fixed for several years now but still hasn't happened and we get further exasperated when employees call EM's customer service who don't know any better and are told that we are charging them wrong which turns into a big mess before we get someone high enough to tell them the authorization charges apply only to complete frame and lens only packages. Grrr!

----------


## Johns

> Thanks for the info - it was very helpful. As an  employer, claims expense is a major consideration, however we also look  into other factors such as network access, out of pocket costs to the  participant, customer service metrics etc.


If access to care it truly a consideration, then Eyemed beats VSP hands down.  VSP,by  design, restricts it's panel to only OD owned offices.  That eliminates  Ophthalmologists and Opticians right off the bat.  In a few cases, they  have been pressured to open panels to a select few chains, but MDs and  Opticians are still, for the most part kept out.

Whether it's  healthcare, eyecare, or a 401k, my employees want choices.  VSP is VERY  limited as to the type of facility they can go to.  Very little choice there.




> ...it can be misleading because it's easy to manipulate discount and retail  prices when the VCP and manufacturer are one and the same.


Bingo.

----------


## rdcoach5

> why not just give them a flat amount to use towards eyewear/eyecare?



ding ding ding ding !!!! Winner !!!
What a concept. Eliminate the cost of the insurance beauracracy.

----------


## Uncle Fester

> ding ding ding ding !!!! Winner !!!
> What a concept. Eliminate the cost of the insurance bureaucracy.


I agree but is it insurance?

From the workers standpoint I believe it's a benefit to the large pool of people insurance or managed care providers have and if they can take a piece out of the pie or better still, from their point of view, limit access to the pie...

The bottom line is the bottom line for all of us.

(NSB1981- sorry for the hijack about to take place!)

----------


## AustinEyewear

> It's been my individual experience that with vision care (like most other things) you get what you pay for... if you want to spend only the $150 or so frame allowance and covered lens options, you can, with the understanding that you'll get what you paid for. What is important is that the participant has a choice - they can choose between a basic product with little OOP expense, or a better product which they'll have to pay out of pocket for but for which the plan still offers value.


Absolutely.  Its our opinion that none of the vision insurance plans cover much in terms of materials, and it sets many patients up for disappointment because they are led to believe in so many words that there will be no out of pocket costs.  The plans are great for preventative health maintenance - getting your employees in for regular eye exams can catch many disease early, reducing your other medical costs, and patients are generally happy with this portion of these plans, although some do get upset by co-pays.  But as far as glasses go, the "covered" options are very limited.  They have to be, or the insurance company would have to charge more. We like to get the patient thinking of them as a down payment towards something better, so they see better, and get better quality.  Of course, not everyone can afford this, and at least these plans get them seeing.  Not necessarily in style, but at least they can see, and importantly, get regular exams

----------


## Gawthorpe

Hello NSB1981:
This is a great topic and I wish more benefits managers took the time to ask the same question. Yes, as a couple of other posters have mentioned there is a "cost" shift from the premium to the employee out of pocket. I know that provider and member satisfaction certainly fall when your employee is "surprised" by their out of pocket costs.   

If you would send me a PM I can forward you a couple of third party reviews of both VSP and EyeMed.  You might also want to search for the Consumer Reports Dec. 2010 article that evaluated different types of providers.

----------


## GokhanSF

I wouldn't choose either one. Look into Spectera

----------


## Uncle Fester

> I wouldn't choose either one. Look into Spectera


Stop that! They may believe you!!!

----------


## GokhanSF

> Stop that! They may believe you!!!


Haha... I am just saying that because I got couple customers who worked for Intel (I believe) and they were allowed to spend $500 without any limitations according to their plan. It might not be the same for other employers though...

----------


## Barry Santini

I think employers should give a flat fee toward eyewear, say $50 max. Online can easily supply a pair for that cost. What? Not the standard of care you want? Well, then the real questions then are: Just what standard can u afford? How do you ensure whatever standard you desire? What's the economic incentive to provide more than the basics?
B

----------


## Uncle Fester

> I think employers should give a flat fee toward eyewear, say $50 max. Online can easily supply a pair for that cost. What? Not the standard of care you want? Well, then the real questions then are: Just what standard can u afford? How do you ensure whatever standard you desire? What's the economic incentive to provide more than the basics?
> B


 Don't many already do a variation of this via a flexible spending account?

----------


## rdcoach5

> Don't many already do a variation of this via a flexible spending account?


Yes, a flex spending account is way preferable to offering a plan that forces you to use a sub-standard choice. If you want to offer your employees a plan comparable to MEDICAID then offer them Spectera.Enough said.

----------


## LENNY

> Yes, a flex spending account is way preferable to offering a plan that forces you to use a sub-standard choice. If you want to offer your employees a plan comparable to MEDICAID then offer them Spectera.Enough said.


Medicaid is much better! Free replacements for the needy!!!!

----------


## drk

Ah, the debate about the usefulness of the vision care plans.  

They serve the providers and the plans, but not the members or employers.  

The only good thing is that members get to spend pre-tax dollars.  That's the only good thing.

We could solve this problem immediately if we were to just tax-exempt monies spent on our health care.

----------


## kcount

> Ah, the debate about the usefulness of the vision care plans.  
> 
> They serve the providers and the plans, but not the members or employers.  
> 
> The only good thing is that members get to spend pre-tax dollars.  That's the only good thing.
> 
> We could solve this problem immediately if we were to just tax-exempt monies spent on our health care.


I'll vote for that!   A definite +1!

----------


## n711

> I wouldn't choose either one. Look into Spectera



There IS a reason they call it "SpecTerrible".... hmm, wonder why they changed their name! hahaha  :Giggle:

----------


## susy

> ding ding ding ding !!!! Winner !!!
> What a concept. Eliminate the cost of the insurance beauracracy.


Vision Essentials by Kaiser Permanente already offers flat allowance plans. Very easy to administer and gives patients the greatest flexibility to choose the product on which they want to spend their benefits.

----------


## Optical Options

I am a Ohio Optician owned practice with out a eye doctor on premises. Eye med sent a letter of rejection to my practice due to it not being full service yet 
another optician owned practice with out a eye doctor on premises is on the Eye med network 2 miles from me. Not that I believe eyemed or lux is God but everything helps. Does any one have any advice?

----------


## npdr

Dear Optical Options,

There only a few alternatives for you. In reference to the colleague 2 miles away, that may be a "grandfather" who got in before the new requirements.  

1. Negotiate for an onsite OD
2. Buy $20,000 worth of Luxottica frames and you will probably get on EyeMed

----------


## racethe1320

> Ah, the debate about the usefulness of the vision care plans.  
> 
> They serve the providers and the plans, but not the members or employers.  
> 
> The only good thing is that members get to spend pre-tax dollars.  That's the only good thing.
> 
> We could solve this problem immediately if we were to just tax-exempt monies spent on our health care.



You need to spend a day on calls with the local VSP Sales rep calling on clients and then enjoy some joint conversations with the benefits managers.  You're local, call them.  I bet you might find they'd entertain you.   :Wink:

----------


## Johns

> Dear Optical Options,
> 
> There only a few alternatives for you. In reference to the colleague 2 miles away, that may be a "grandfather" who got in before the new requirements.  
> 
> 1. Negotiate for an onsite OD
> 2. Buy $20,000 worth of Luxottica frames and you will probably get on EyeMed


There are others.  I'll pm you.

----------


## Barry Santini

> Why not just give them a flat amount to use towards eyewear/eyecare?


If *I* were a benefits administrator, I'd contract with Zenni and give the members a $30.00 gift certificate.

That. Should. Do. It.

B

----------


## kentmitchell1961

[QUOTE=optical24/7;424750]Almost all VSP providers also accept EyeMed vs All EyeMed providers aren't allowed to accept VSP. As example independent opticians can accept EyeMed but are blocked from VSP. (There's some dang good opticians that own their own place.)

I work for an independent that happily takes both.  VSP web page is a bit of a nightmare compared with eyemed and won't let a patient use non vsp labs (so no Mauis or Oakley sun) but are reliable and have good customer service.  Eyemed does not really care what lab you use but cs can be dodgy.

----------


## rdcoach5

> If *I* were a benefits administrator, I'd contract with Zenni and give the members a $30.00 gift certificate.
> 
> That. Should. Do. It.
> 
> B


Quit saying that, they might take you seriously.

----------


## penny

For the optometrist it's a real pain to file a claim for any assignment claims through Eyemed. It's going to take the front office a lot of time on the phone to find out if the patient is eligible, then you have to fill out the online form with patient's information and then the employee's information all over again.  There is no box to check that the dependent and employee have the same address, phone number etc. So if you get a husband and wife with 3 kids you'll be filling in the address, phone number, marital status, student status, 9 different times to get a measly $40 each for your exam. I complained about it.  It should be easy to just have a box to check (similar to when the billing and shipping address are the same for credit card orders) but with this company nothing is ever done to increase efficiency.

----------


## jmainwar

[QUOTE=kentmitchell1961;438238]


> Almost all VSP providers also accept EyeMed vs All EyeMed providers aren't allowed to accept VSP. As example independent opticians can accept EyeMed but are blocked from VSP. (There's some dang good opticians that own their own place.)
> 
> I work for an independent that happily takes both.  VSP web page is a bit of a nightmare compared with eyemed and won't let a patient use non vsp labs (so no Mauis or Oakley sun) but are reliable and have good customer service.  Eyemed does not really care what lab you use but cs can be dodgy.


Use the special lens allowance, quite easy after spending an hour studying it and can you a little more if your prices are right.

----------

