REIMBURSEMENT ISSUES

Most Health Insurers Say No

Although precise statistics are unavailable, we estimate that there are about 50,000 people in the U.S. who can benefit from our sight-restoring Boston Scleral lens.  But numbers alone do not tell the full story.  Consider that the vast majority of our patients are young, in the prime of life.   Some are children.  Most have exhausted all other options for regaining functional vision and many face a lifetime of relentless eye pain and disabling sensitivity to light.  The Boston Scleral Lens is their only hope for regaining functional vision and finding relief from the pain that dominates their every waking moment.  For others it represents an alternative to corneal transplant surgery with its potentially serious complications, long recovery time and uncertain visual outcome.  What is the monetary value of giving them the opportunity to reach their full human potential, eliminating their need for welfare and disability support and enabling them to become productive tax-paying members of society? The answer of most medical insurance companies in the U.S. is: “Fitting the Boston Scleral Lens is not a covered service.”  This is not an experimental procedure.  Approved by the FDA in 1994, the Boston Scleral Lens has proved its effectiveness in hundreds of patients and our results have been reported in the top peer-reviewed medical journals.  This is the ultimate irony: a safe procedure that provides the immediate and priceless gift of sight for less than $8,000 is denied coverage while corneal transplant surgery is covered.

Because many of our patients have been profoundly disabled for years—some for decades, most have exhausted their savings and that of their families. Can we deny them the right to see because they can’t afford to pay? Our answer is a resounding “No”. As a result, more than half of our patients depend on the compassion, generosity and charity of strangers in order to rejoin the mainstream of society. This should not happen in the wealthiest nation in history whose citizens are protected by the Americans With Disability Act. What is wrong? The answer is: they are the victims of powerless bureaucracy and a medical delivery system that is unresponsive to one of the most basic medical needs of society.

What is the process for securing insurance reimbursement for a new medical procedure?

A new CPT Code: the first step (a catch-22 in our case)

This code defines each medical procedure and establishes its relative reimbursement value. Since none of the existing codes or their modifications are applicable to fitting the Boston Scleral lens, we applied for a new CPT code. It was denied—as was our appeal. The reason: “Your procedure is not widely available.” The requirement that a new medical procedure be widely available in order to be issued a new CPT code, has in this instance, insured that the Boston Scleral Lens will never be widely available since other academic eyecare centers in this country are hesitant to offer a costly non-reimbursable procedure. This provision, presumably meant to protect the interests of consumers, serves in this case to deprive tens of thousands of citizens of a basic human right: the right to see. We need to change this rule or be granted an exception.

Securing coverage: the second step

Health insurers are not legally required to provide coverage for a medical procedure even when it is defined by a CPT code. Their decisions are based on competitive market forces. Orphan devices like ours that have a very limited constituency and lack the power of numbers are not even on their radar screen. But they do yield to public and political pressure. How else can one explain the enlightened policy of many insurers of covering breast implants while denying coverage for a procedure that, for many, represents the only means of restoring functional vision.

Securing adequate payment: the final step

The battle is not over with the issuance of an appropriate CPT code and classifying the Boston Scleral Lens fitting as a covered service by health insurers. A far greater threat to the survival of this vision-restoring technology would be the decision of health insurers to assign a fee that is less than our clinics’ costs. This is not a theoretical possibility. It has happened in the past. Since most provider contracts prohibit balance billing, this decision would be tantamount to imposing a loss on the clinics for every patient fitted with the Boston Scleral Lens even for those who can afford and have the desire to cover the costs of the procedure. Is there a way to bring forces to bear to correct this injustice?

We need your help!

As our vision-restoring contact lens devices become more widely known among our colleagues in the eyecare profession, the number of desperate patients referred to us continues to grow and this success is testing the limits of our financial and physical resources. The need to establish this technology in other centers is becoming more urgent. Yet, the uncertainty of insurance reimbursement represents a major disincentive for academic eyecare clinics to offer this life-changing treatment and we need your help to correct this injustice.

The public media

Journalism is one of the bulwarks of a democratic society. We need to get the word out and recruit this important resource. Help us reach the print, radio and TV journalists who can make a difference in our quest to correct this discriminatory practice.

The political establishment

Who are better equipped to correct injustice in our society than our elected officials? Who are more responsible for protecting the rights of the underserved in our communities than our elected representatives? Help us to enlist their support for this mission.

Financial support

In the absence of insurance reimbursement, it has been necessary for us to subsidize the costs of fitting the Boston Scleral Lens for over half our patients. And as their numbers rapidly increase, our ability to serve them is jeopardized. The right to sight should be a birthright and not a privilege. But until it is, we need your help if we are to continue to offer our life-changing lenses to those in need and turn no one away because of their inability to pay.

If you are moved to support this effort, please contact us at info@bostonsight.org or call the Boston Foundation for Sight at 617-735-9330.

Perry Rosenthal, M.D.
Founder and President

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