Article Date: 8/1/2011

Both Parties (Not Just Us) Must Adhere to Contract Agreements
The Business of Contact Lenses

Both Parties (Not Just Us) Must Adhere to Contract Agreements

By Clarke D. Newman, OD, FAAO

Returning just a bit to the insurance side of the contact lens equation, I thought I would talk about contracts for just a second. Throughout our time in practice, we sign myriad contracts with a variety of people. Most of the time, the contracts are offered to us by people or entities that are exchanging something of value to us for services rendered.

We don't write most of these contracts. They are written by the other party. Usually, these contracts have many clauses in them that tip the playing field in the direction of the party that wrote the contract.

If you lease your office space, you will have a contract with a landlord. If you lease or purchase a piece of equipment, you will have two types of contracts—a sales agreement and a warranty. Both of these types of contracts are written to the advantage of the other side.

Protecting Yourself

That brings us to insurance providers. We contract with these providers, and most of the provisions in them favor the providers—by a bunch. The various carriers have absolutely no honor code about holding our feet to the fire when it comes to our adherence to the provisions to which we have agreed. It is in the carriers' interest to employ departments of compliance people to protect their interests.

We should do the same to them.

Too often, we do not bother to enforce the contract provisions that protect our interests, and that failure costs us money. First, if there are no such provisions, then don't sign the stupid thing to begin with! For every contract offered to me by carriers, I reject around half, if not more, because they do not make good business sense for my practice.

When a company does not do what they agree to do, hammer them on it. Almost all of the contracts have a non-retaliation clause in them. So, you have the right to enforce your side of the bargain without the fear of being dropped. If you are dropped, or otherwise penalized for sticking to your guns, then you have a material breach that may be a tort worthy of pursuing in the courts.

Be Aware of Amendments

Second, many of these contracts have provisions for amendments. These are always one-sided. You do not have the right to amend the contract, but they do, and your signature on the contract is an agreement to this arrangement. One thing to guard against, however, is the wiping out of one provision of the contract by an amendment.

For example, a big carrier agrees to abide by CPT, but then amends to say that topography is part of a comprehensive general ophthalmological code. No, it isn't. Topography has its own code and description, and is nowhere in the preamble or the plain language of the 92004 or 92014. Fight them on this stuff. You signed the contract with the reasonable expectation that they would abide by CPT, and they are changing the game here. What if they said that everything, including cataract surgery, was part of a 92004? Would you sign that contract? No, you wouldn't. To amend without renegotiation would significantly alter the nature of the contract.

Don't sit there and take it. Fight it all the way to the state insurance commission and the attorney general or take them to arbitration or court as a last resort.

Contract law is contract law, and both sides must adhere, whether you are a solo practice practitioner or a multi-billion dollar corporation. CLS


Dr. Newman has been in private practice in Dallas, Texas since 1986 specializing in vision rehabilitation through contact lenses as well as corneal disease management, optometric medicine and refractive surgery. He is also a consultant or advisor to B+L. You can reach him at cdnewman@mindspring.com.

Contact Lens Spectrum, Issue: August 2011