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Although federal statute governs the Medicare program, each carrier may administer the program in slightly different ways. An example of this is a requirement by some carriers that mandates that the resident's primary care physician must first evaluate the resident and issue a written order for a specific optometric service prior to an optometrist being able to see the resident and seek reimbursement for those services. The following are examples of reimbursement mechanisms or policies which carriers may apply. Health care delivered to a nursing facility resident is under the direction of the attending physician. Medicare Part B guidelines state that a facility must ensure that the medical care of each resident is supervised by a physician and that physician's visits must take into account the resident's total program of care, including medications and treatments.10 The primary physician retains the overall responsibility for the coordination and direction of the resident’s care. In order for an optometrist who provides services to a resident to obtain Medicare or Medicaid reimbursement for those services, the resident’s physician must first have a written order for those services. The attending physician not only performs periodic examinations and assessments of the resident but also coordinates the entire care of the individual. If physical therapy, blood tests, or an eye examination is needed, the attending physician must authorize the service through the issuing of a physician order. There may be some overlapping of eye care services between the primary care physician and the optometrist in the nursing facility, just as there is in clinical practice. For example, if a resident presents with conjunctivitis and the primary care physician is comfortable in managing it, an order for optometric services may not be written. If, however, the physician is not available to diagnose the condition, or wishes to have an optometrist examine and treat the resident, it is the physician who has the ultimate authority to write the order for optometric services to be performed. Even though the optometrist may have treated the resident previously, the optometrist has no authority to examine the resident and obtain reimbursement unless a specific order has been written by the attending physician. Close communication between the nursing facility staff, nurses, attending physicians, and optometrist is essential for this system to work effectively and in the resident’s best interest.
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