The burden of dry eye disease (DED) is not only physical and psychological but financial as well. Given the chronic nature of DED, most patients will require some form of long-term therapy, and the costs associated with these treatments are often near the top of their list of concerns.
In 2011, the estimated direct economic cost to the US healthcare system for dry eye therapy was $3.8 billion per year, and the estimated total societal cost was more than $55 billion per year.1 More recently, dry eye medications have shown to be the highest expenditure of all ophthalmic medication classes, per capita, in the US.
Another 2017 study looked at how DED impacted work productivity and worker presenteeism and absenteeism.2 In a survey of over 500 office workers, approximately 7 out of 10 reported some inhibition of daily activities due to dry eye symptoms. In these patients, DED can be due to environmental conditions, such as poor air quality and digital device usage.3
Insurance considerations with DED
“Will my insurance cover that?”—optometrists and technicians are almost guaranteed to hear this question when discussing DED treatments and therapies. The answer can be tricky depending on the treatment plan recommended for each patient.
We can break down DED treatment options into three major categories:
- Topical prescription medications
- In-office procedures
- Over-the-counter (OTC) therapies and supplements
Prescription medications
While most prescription medications for DED are now covered by insurance, it will often depend on the patient's plan. However, there can still be obstacles to payment.
Among the most common complaints against insurance carriers:
- The payer prefers one medication over another.
- The payer requires a lengthy prior authorization process before coverage for a specific medication is approved.
- The payer demands step therapy or proof of prior failed therapies before a higher-tiered or non-formulary option is covered.
Tips for increasing insurance success with prescription meds
As new medications come to market, the insurance coverage landscape is ever-changing and sometimes it may feel like it’s increasingly harder to get our patients the specific treatment the doctor recommended.
Here are some tips that can make navigating this maze a little easier.
1. Utilize your drug representative’s expertise.
Drug reps can be an invaluable source of information; every year, as prescription plans change, some drugs move up or down the tiered coverage system, and some get added or dropped. Beyond keeping your sample closet fully stocked, drug reps can help keep you up to date about the status of their specific drug on the most common insurance plans in your state.
At the same time, they can keep you up to date on savings programs and patient assistance plans available. Saving programs are a great way to ensure patients adopt the recommended therapy faster and at a lower cost, especially when it comes to newer therapeutics that are likely to be on most insurance formularies' higher tiers, if at all.
Unfortunately, most savings and access programs are only available for commercially insured patients. Patients who participate in government-sponsored health plans, such as Medicare and Medicaid, are ineligible.
2. Take advantage of online tools.
Become familiar with online prior authorization tools. Software like ParX Solutions and CoverMyMeds can help save you time in completing the tedious task of completing prior authorizations in a simple and automated way. These services are free to use, can help expedite the process, and allow you to keep track of all your active and pending prior authorizations.
3. Never underestimate the power of documentation.
Document, document, document. A robust medical history and detailed documentation of prior failed therapies, inadequate efficacy, and intolerance or adverse reactions patients may have experienced can help expedite the prior authorization process and ensure patients receive the recommended therapy faster. All these will be required during the determination process and can save you valuable time if already on hand.
In-office procedures
While advancements in technology have provided us with a variety of novel and advanced treatment options for the different types of DED, the insurance apparatus has not quite caught up with them. Insurance coverage for most of these treatments—intense pulsed light (IPL), LipiFlow, radiofrequency (RF), etc.—remains inconsistent, as most of these are still considered to be cosmetic or elective.
Most insurance companies do not cover these treatments. However, the rare ones that do assess on a case-by-case basis and require a lengthy pre-determination process requiring thorough documentation of medical necessity and prior failed therapies like prescription and topical options.
Educate patients on recommendations and resources
Patient education is paramount when discussing treatment-associated costs. A patient who understands the underlying reasons why a treatment is being recommended and how it will impact their symptoms, as well as the risks, benefits, and alternatives associated with said treatment, is likely to be more empowered to make an educated decision about their own care.
While insurance companies may not cover many of these treatments at the moment, there are a range of resources you can offer to ease the financial burden. Fortunately, the majority of treatments available today qualify as Flexible Spending Account (FSA) or Health Savings Account (HSA) purchases, if available at your practice.
In addition, financing through services—such as CareCredit, Alphaeon, and SunBit, among others—is also a possibility worth offering our patients to cover the unexpected costs some of these treatments may carry.
In recent years, some of these procedures have been assigned temporary codes by some insurance carriers for the purposes of identifying and tracking new technologies and services. Unlike a CPT code, these category III codes, often labeled with a capital “T” are non-billable codes and, often do not reimburse enough to cover the cost of the disposable supplies needed to perform the treatment.
For instance, 0507T is the temporary code assigned to near-infrared, meibomian gland imaging (Lipiview, LipiScan), and 0207T is the temporary code assigned to the automated evacuation of meibomian glands (LipiFlow).
Over-the-counter topicals, therapies, and supplements
The DED space is filled with hundreds of different products that offer instant relief of signs and symptoms. Convenient online retailers provide access to a wide selection of OTC therapies, but, oftentimes, do not provide adequate safety and efficacy data. Therefore, patients often find that determining the right combination of products for their needs to be an overwhelming task.
Artificial tears and lid scrubs hold an important place in DED treatment and management; however, not all products are created equally. In addition, supplements can prove very beneficial, but the nutritional supplement industry is poorly regulated in our country, making it complicated for clinicians and consumers alike. While some products may prove to be beneficial to some patients, they may be ineffective for others.
Supply recommendations based on individual needs
Rather than allowing patients to try every single product offered on the shelves in hopes of finding one that works, assist them by narrowing down the selection. Make a list of trusted and well-researched products and then offer recommendations to patients based on their specific needs.
This will not only simplify the process and reduce costs, but also ensure patients are using safe and trusted products while avoiding potentially harmful ingredients and products of dubious provenance.
Final thoughts
Conversations about pricing and costs associated with treatment are a gray area of healthcare that clinicians often find daunting. However, as patient counselors and advocates, it is critical to become well-versed in the subject matter and comfortable with these discussions.
Once the doctor has completed their exam and recommended the best treatment plan based on the patient’s specific needs, it is time to broach the topic of payment. First, outline the benefits/risks and alternatives of the proposed treatment. Next, we can offer our patients many resources for savings and payment options.
Approach the cost conversation with confidence, compassion, and the goal of empowering patients to take charge of their ocular health and more effectively manage their DED to improve vision and quality of life.
