Optometry Australia says it is working with all private health funds towards standardisation, as practices continue to navigate a “minefield” around inconsistent claiming rules with frames, lenses and contact lenses.
It comes after the organisation released the latest update to its ‘Private health insurance rules & rebate conditions’ guide, which it began producing eight years ago.
“Health fund entities set their own requirements around claiming for ancillary services, and due to the varied and confusing rules currently in place Optometry Australia developed a private health insurance claiming guide back in 2017 to help members navigate this ‘minefield’,” OA said.
“Claiming rules have often changed across this period and our November 2024 guide is currently on its fifth update.”
A common question practices grapple with is whether a product can be purchased over two years (frames and lenses) to maximise rebate. While most don’t permit this, some do, with some conditions.
Another example is whether a benefit can be provided on a frame-only purchase, if the patient chooses to get lenses elsewhere.
One independent Insight spoke to said a major problem was incontinences around whether patients could use the benefit as a deposit, or claiming before the spectacles were fully paid for.
There have also been cases where practices have been asked to refund the health fund for frame-only purchases as the patient is meant to claim only after ordering frames and lenses.
It can be a total quagmire of problems, they said, when health funds become dogmatic about their rules.
OA said communication of rules and changes with eyecare providers was often “lacking”.
“As an example Optometry Australia is currently negotiating with one provider for audit repayments to be refunded to members – penalised for not following rules which they were never informed about,” the organisation said.
“Work is ongoing in 2025 with all private health funds to help simplify and standardise claiming rules in the optometry sector.”
Dr Rachel David, CEO of Private Healthcare Australia – the private health insurance industry’s peak body with 22 registered health funds representing more than 98% of policyholders – said the organisation was “keen to engage with Optometry Australia regarding any proposals to improve our private health system”.
“We welcome any suggestions for our member funds to consider,” she said.
More than half of Australians (54.6%) have extras cover that includes optical and other services like dentistry and physiotherapy. The average benefit paid per optical service is $82, in the latest data, with $212.3 million in benefits paid in the September 2024 quarter.
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