Optometric Management Tip # 560   -   Wednesday, November 28, 2012
Billing Medical Insurance or Vision Plans?

Optometrists are both blessed and cursed to be paid by two forms of third-party managed care plans: medical insurance and vision plans.† Usually I feel more cursed than blessed, but I firmly believe in playing the cards weíre dealt, so letís look at ways to determine when to bill which plan, given the system we have in place in the United States.† I will say at the outset that I donít have all the answers to the complex issue of how to bill insurance companies for the legally maximum amounts while keeping the patient perfectly happy.† I think itís important to balance those two factors and recognize that there is a gray area between routine vision care and medical eye care that must be handled well.

Bill the plan that pays the best
There are many circumstances where an eye care provider (ECP) could bill either a vision plan or a medical plan for the same visit.† It is, of course, illegal to bill both plans for the same work, but it can be perfectly legitimate for the doctor to choose one plan or the other.† Vision plans approve claims based on the calendar.† As long as the patient is eligible, the diagnosis does not really matter.† Medical insurance approves claims based on an appropriate medical diagnosis and medical necessity.† If a patient has both types of insurance and if there is an appropriate medical diagnosis, either plan could be billed and will be paid.

In the absence of any other factors, it makes perfect sense to bill the plan (and the specific code) that pays the best (usually the medical plan).† But there are many other factors.† Vision plans generally pay much lower fees than medical plans and they clearly indicate that the covered service is a routine vision exam.† So when does a routine vision exam become a medical exam?† Many ECPs have office policies and definitions to try to differentiate the two types of exams, but it is still quite common (and understandable) for patients to be confused.

The gray area
Many case examples are extremely easy to determine if they are routine or medical.† A patient who has no complaints or only wants to check if his prescription for glasses is correct should use a vision plan.† A patient who is a glaucoma suspect or has a foreign body in his cornea should use medical insurance.† But there are a large number of cases that may not be so clear.† Some medical diagnoses are rather minor in nature and do not need additional treatment or follow-up.† There is wide variation among ECPs on how to handle the cases in the gray area and even on what is the gray area.

The patient is a stakeholder
Itís important to consider the patientís point of view as the decision is made about billing vision plans or medical insurance.† The terms of all these plans vary, but it is quite possible that the medical plan can carry a higher co-payment amount or the vision plan may have zero co-pay.† There may also be a high annual deductible with medical insurance that has not been met.† The medical plan may not cover the refraction test (but some do).

If the practice makes the unilateral decision to bill the medical plan without educating the patient, itís quite easy for patients to be unhappy with their part of the bill.† The patient may complain to the front desk staff in some cases, or may not say anything and just decide to not return for future care.† It is clearly not a good strategy to be paid a higher exam fee, only to lose the patient and his family forever.

Some insurance management tips


Best wishes for continued success,

Neil B. Gailmard, OD, MBA, FAAO
Chief Optometric Editor, Optometric Management