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 By Neil B. Gailmard, OD, MBA, FAAO, Editor November 28, 2012 - Tip #560 
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Billing Medical Insurance or Vision Plans?


  Sponsor: ICaps® Eye Vitamins

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 we're dealt, so let's 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 don't 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 it's 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
It's important to consider the patient's 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, it's 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

  • Have a patient handout that explains the two types of insurance and defines routine vision exams and medical eye exams.  A one-page handout is actually your office policy written in simple language.  It can be used for patient education and it also reminds staff members of the key points and works like a script.  I'll give an example in a future tip article.
  • Tell patients in advance.  This goes a long way to keeping patients happy.  Many successful practices train the front desk staff to take a mini-history over the phone as the appointment is being made.  If the nature of the complaint or history is medical, the staff member can indicate right then that a medical eye exam is needed and that your office will be billing the medical insurance.  It is always better to discuss these matters before the services are performed.
  • Always obtain both the vision plan and medical plan information over the phone.  This task alone will educate patients as many will ask why you want it.  This is a clue that this patient does not understand that eye doctors can provide medical care and there is a high likelihood of confusion about insurance.  Your staff should see this as an opportunity to provide patient education.  Some patients, however, will not want to hear the education.
  • Learn about the insurance plans that are common in your area by keeping a log book about what they cover and how much they pay.  This should be specific for the employer or group since each insurance company has many different plans. 
  • Help the patient as much as possible with keeping his out-of-pocket costs low.  After all, that is the main concern the patient has with regard to which insurance is used.  Patients don't know the specifics about their vision or medical plans, so help them with it.  In many cases, the difference in the out-of-pocket dollars is not that great.  If you can show that, then all the fuss goes away.
  • Find out which services go toward the deductible for all the medical plans you see.  Many medical plans do not apply office visits to an annual deductible at all, but rather only the co-pay applies.  If that is the case, high deductibles do not cause any problem at all.  This could be different for 92 codes vs. 99 codes.
  • Consider coordination of benefits.  In many cases, you can bill the medical plan for services, including non-covered items like the refraction.  When the payment and explanation of benefits (EOB) is received by your office, you may be able to send the claim on to the vision plan with a copy of the EOB.  The vision plan may pay up to the plan limits for the non-covered amounts.  The vision plan may even pay the medical co-pay.  You may need to file a paper claim for these cases.
  • Don't reappoint unless you really need to.  This is another sensitive area, but many ECPs routinely make the first exam visit go to the vision plan and if there is a medical diagnosis, they bring the patient back for additional tests and those are billed to medical.  This is a perfectly fine way to go and it is very clean, if additional testing is needed like an OCT or visual field.  But if the second visit is simply to examine the same thing that was seen at the first visit, patients and insurance plans will rightfully have an issue with it.

Best wishes for continued success,

Read Past Tips Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week


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Send questions and comments to neil@gailmard.com.

Dr. Gailmard offers consulting services to eye care professionals through Prima Eye Group; information is available at www.primaeyegroup.com.

Please Note: The views expressed in Management Tip of the Week do not necessarily reflect those of the sponsor.

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