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This makes the MDS assessment of visual status crucial in initiating vision care. The MDS is updated yearly, with significant changes in status, or with discharge and readmission. Optometrists can be immensely helpful to nursing facility staff and residents by reviewing and addressing shortcomings in MDS evaluation and care plans for vision. Access may be the most challenging and important component of providing care to nursing facility residents. Failure to follow regulations can result in fines, penalties, and possible sanctions against those participating in government programs. It is the provider's responsibility to research and understand Medicare/Medical Assistance (Medicaid) policies and to be certain that the optometrist and optometrist's employees are following them. Described below are general concepts regarding government compliance issues. Each state and carrier may have specific rules and regulations unique to that area. Optometrists should research and read all provider manuals and contact their local state association and Medicare/Medical Assistance carriers for specific local policies. Several different individuals or processes may identify a resident’s need for optometric services. These include requests from the director of nursing or social services, the attending physician, the resident or family themselves, through the MDS assessment process, through a pharmacy request for consultation, or as a referral from a visual screening. While identifying the need for optometric services and obtaining authorization to examine the resident is the first step, following the correct protocols for reimbursement is equally important. Recent interpretations of federal statutes by regional Medicare carriers have made it incumbent upon optometrists to understand the role of the attending physician in approving eye care services. As outlined below the attending physician clearly plays a key role in assuring that optometric services are indicated and therefore covered by third party payors. Interpretation of these guidelines may also cover the ability to access residents even when third party payors are not involved. Individual Medicare carriers are responsible for applying these guidelines to providers in their area. The importance of knowing local third party payor regulations for access to residents and requirements for reimbursement cannot be over emphasized. Many residents have Medicare coverage and, just as in the office, Medicare requires a symptom or complaint for the visit to be covered. Refractions and screenings are noncovered services under the Medicare program. Each state may have different rules and benefits that cover Medicaid recipients. Some states allow "routine" examinations and eyeglasses, while other states may have less generous benefits. Recipients that are covered by ERISA plans or indemnity plans will have quite different coverages. Health maintenance organizations (HMOs) may have even more specific guidelines and include restrictions such as using a gatekeeper. The provider must be familiar with all plans for which services are provided and be certain to remain in compliance with all of their rules and regulations. Medicare, a federal program that is administered by state or regional carriers, will be the primary insurance for most nursing facility residents.
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