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 By Neil B. Gailmard, OD, MBA, FAAO, Editor June 4, 2014 - Tip #637 
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Routine Vision vs. Medical Eye Exams: Fees and Insurance

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Optometrists are doing a much better job with the medical model of eye care, but this is still a sensitive area in practice management because patients naturally want some input into whether we bill their vision plan or medical insurance. Two major factors to consider are the exam fee structure and how to decide which insurance to bill. I'll present an analysis of both these factors here, along with some tips on how to bill for the maximum fees without upsetting the patient.

A good place to begin your fee strategy is to decide if your practice should have a lower fee structure for routine vision exams compared to medical eye exams. If the patient has a vision plan that the practice accepts, it may not make any difference because the practice ultimately accepts the vision plan payment, but in some cases, routine vision exams are private pay. It is not an easy decision but we should start there.

Let's begin by looking at medical eye exam fees because they are a bit easier to determine. Many doctors use the published fee levels for Medicare as the minimum to charge for a service. You could use any medical insurance plan fee schedule as your basis, but Medicare is often considered the standard. This makes sense because doctors want to be paid the maximum for a service and the popular expression is that we don't want to "leave money on the table" by billing less than insurance will pay. Of course, you could charge more than the approved amount and many doctors do, but that fee will be adjusted down to the approved fee level and you can't balance bill the patient for covered services.

S-codes and TOS discounts
For a 92014 the Medicare approved fee is about $126. That does not include refraction and let's say that averages about $35. So the eye exam with medical insurance is at least $161. So, will a routine private pay patient pay $161 for an eye exam? In many cases, they will. I know many ophthalmological and some optometric practices that charge more than that to private pay. My practice charges more than that and we only have one comprehensive exam fee for all types of patients, regardless if it is routine or medical, regardless of no insurance, vision plan or medical insurance. If you can charge the same fee to all, then you don't need S-codes or a time of service (TOS) discount.

But many practice owners feel they would lose a lot of patients if they charged that high of a fee for a routine exam. There are always optical places in every community that charge very low exam fees. If you feel you need a lower fee for routine and private pay, then S-codes or TOS discount are both good ways to go. To my knowledge, there is not a published maximum for TOS discounts but it must be reasonable and represent the true administrative cost that would be incurred for billing and collection. If we use 20% as the TOS discount, that would bring the fee down to $128 for the private pay patient. If you feel that is still too high for a routine exam fee, then you can use an S-code like S0621. An S-code exam is a different service than a medical eye exam and it can legally have a different fee. S-codes include the refraction. You can make an S-code exam fee any amount you want. S-codes are never billed to medical insurance; they don't recognize them.

Billing medical or vision?
We give each patient in my practice at check-in a short handout explaining that vision plans only cover routine vision wellness exams, eyeglasses and contact lenses. Medical eye exams (the diagnosis and treatment of eye health problems) are billed to medical insurance. From there, the doctor determines how the case is billed. Much depends on the chief complaint and the medical diagnosis.

  • In some cases, we will bill the vision plan first for a routine exam and reappoint for follow-up medical care which is billed to medical insurance.
  • In some cases, such as emergencies, we perform a medical eye exam and treatment first and then reappoint for a routine exam and refraction.
  • In some cases, we simply do not need to see the patient for two visits within a close time frame and we do not routinely manufacture a second visit. In the first place it would be unethical and in the second place, patients are smart and many will sense the unnecessary visit and quietly change doctors. In those cases, we may bill the vision plan or we may bill the medical plan depending on the primary diagnosis and complaint.
  • We use coordination of benefits with both types of insurance when allowed, which means the vision plan may cover some of the fees that medical insurance does not cover, such as co-pays and refraction fees.

Questions from patients
If patients ask why you have two different exam fees or why you bill medical insurance instead of the vision plan, your staff must explain that a routine eye exam is different than a medical eye exam. A routine exam is faster and easier to perform and there is no medical decision-making or disease treatment in a routine exam. That is fair, but there is a gray area in between routine and medical that the patient may not understand or accept, and ODs need to be careful with that. You might find a very minor medical issue, let's say a very mild dry eye condition that does not require treatment or follow-up. You could insist that it is a medical exam because of that finding, but the patient may feel that he did not really have a medical problem and he just wanted an exam for new glasses.

I let the patient win on borderline medical cases like that and also if I know there is a high medical deductible in play (if there is an exam co-pay, the deductible is usually not a factor). I just consider those exams as routine and bill them to the vision plan. My practice treats and bills a high number of medical cases, but the patient relationship is more important than a higher exam fee. If a case is clearly medical and the patient still objects - let's say diabetes for example - I might let the patient have his way on this initial visit, but I'll explain that he has a chronic medical eye problem that requires a higher level of care and in the future, we will have to charge a medical exam fee and bill medical insurance. We mark the record accordingly so my staff knows how to handle it next year and we know what we said. I might lose a few of those patients next time, but that is OK with me because I'm doing the right thing. I will keep most of them and I let the patient get out of the issue gracefully the first time. I also avoid a negative online review and bad word of mouth and I keep the stress level low for my staff.

There is usually a way to achieve your business goals and keep patients happy if you work on 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.

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