Article Date: 6/1/2013

Maximize Your Vision Plan Reimbursement

Maximize Your Vision Plan Reimbursement

Success is contingent on your knowledge of the plan.


When 16th century English author, Sir Frances Bacon wrote, “Knowledge is power,” he was referring to religion. Yet, this statement easily applies to profiting from vision plans: You must know each plan’s reimbursement fees and rules regarding provider services and retail, and weigh that data against your patient volume and the true revenue per patient encounter.

Here, managed care experts explain how you can maximize your reimbursement from these areas.

Provider services

The provider services side is comprised of three entities:

1. Contact lens fittings. Create a fitting fee grid to determine different fitting fees. Next, identify how much you will get reimbursed for each fitting fee: Ask yourself:

Are my fitting fees for each service too low or too high based on what the vision plans pay?

Are my fees too low or too high based on the quality of service I provide?

If a vision plan pays $60 for a contact lens fitting, for example, you shouldn’t charge less than $60, say those interviewed for this article. Also, consider the time involved and difficulty of the fit when setting pricing.

“Don’t be afraid to charge fair market value pricing for your products instead of the manufacturer’s suggested retail price (MSRP),” says Jay Binkowitz, president and CEO, Gateway Professional Network, Huntington, N.Y. “The MSRP does not take into consideration the cost of selling a product vs. the raw cost of the product. The basic rule of thumb for the right selling price is what the consumer is willing to pay for it. This is, in many instances, greater than you would imagine. Testing fair market value is always good business practice.”


Knowledge is power when it comes to getting the most profit out of your vision plans.

In addition, don’t undervalue your expertise in contact lens fitting, stresses Alan N. Glazier, O.D., F.A.A.O., CEO/founder, Shady Grove Eye and Vision Care, Rockville, Md. “Sell yourself as the expert you are, and charge accordingly.”

2. Vision services. Find out what each managed vision plan pays for these services, which are often coded as 92XXX vision exam codes. The exam itself is typically (but not always) a 920XX code. Most plans do not include 92015 (refraction) as a bundled service, and the refraction should be charged separately. This means that you should have separate line items for both the exam service and the refraction procedure. How you decide your fee structure for both the vision exam and the refraction should be based on the level of service provided, the technology used, the typical decision making involved and the regional normative rates — NOT what the vision plan reimburses. If your pricing structure is based only on what managed care reimburses, you are likely undervaluing your services and leaving money on the table, say those interviewed.

3. Medical services. Many vision plans cover medical vision problems to some degree. Determine whether to bill a patient’s vision or medical plan based on the patient’s chief complaint and medical findings — not whether they are covered. In some instances, you must decide which coverage to use, but always be sure to have the appropriate documentation for the exam code used. Read the plans’ contract to determine this on a case-by-case basis. Plans don’t always make this easy to decipher, say those interviewed.


The retail side is made up of:

1. Contact lenses. Identify the plan’s allowance (what the patient will pay) for contact lenses and whether the patient is responsible for a co-pay. Together, these comprise the actual reimbursement. After determining the reimbursement, you can see what you need to charge to make a profit. Once again, on the retail side of the equation, you must determine current market value in your regional area and what the market will bear (i.e. the consumers will pay) to determine the correct pricing. That said, be sure to make the price reasonable, or you may lose the sale, say those interviewed. (See “How to Set Your Fitting Fees,” page 21 of the January 2013 issue.)

Dispensing Second Pairs

Selling a second pair of glasses is key to making large profits. So what are the best ways to go about this?

1. Assess patient lifestyle. “It is important to inquire specifically about hobbies and sports interests, as well as work environment needs,” says Lorie Lippiatt, O.D., president, Salem Eyecare Center, Salem, Ohio, “We also ask whether they [patients] wear prescription sunwear, if lenses are polarized and how current the prescription is. This makes patients realize that not just one pair of eyewear will satisfy all their lifestyle requirements.”

Everyone needs a second pair of glasses, says Dr. Glazier. “As their doctor, you need to point this out. I might mention that someone needs computer glasses more than they need their distance glasses because they are at their desk for 40 hours a week.”

2. Educate patients regarding a product about which you’re excited. “Show patients something you’re excited about, such as polarized lenses,” says Dr. Binkowitz. “Let them know you’re an expert with this type of eyewear.”

2. Frames. Don’t set fees based entirely on what the vision plan pays. Make sure your practice isn’t losing money in the process. To determine the “lowest end,” in terms of pricing, assess the reimbursement and dispensing fee for the various frame-pricing categories. Consider shipping and handling costs, as well. Make a strong effort to dispense second pairs (e.g. occupational lenses, prescription sunglasses, nighttime driving glasses, fashion glasses and sports glasses), say those interviewed. (See “Dispensing Second Pairs,” below.)

3. Ophthalmic lenses. Follow similar guidelines for lenses as you do for frames: Know what vision plans pay so you know what types of materials (e.g. CR-39, polycarbonate, high-index) to prescribe, obviously while keeping in mind the patient’s needs, say those interviewed. Also, consider the modality of lenses you prescribe. Each one is a different category with a different reimbursement structure. For example, for a level F lens you may be reimbursed $40 per lens. Selling a premium progressive lens, such as an N, makes you $80 per lens.

“Ensure patients that you’ll maximize their benefits to get everything they are entitled to,” says Dr. Binkowitz. “Always provide comparative value, let the patients know their savings and the final cost in that order. Never start with the cost, as numbers alone lack explanation.”

An opportunity

Vision plans are an opportunity to gain access to patients, yet becoming a plan provider makes no sense (and cents) if you don’t familiarize yourself with the plans. So, use the general tips outlined above, and take the time to review the plans for which you’re a provider to determine whether you can do anything else to get the most out of your plans. Remember: “Knowledge is power.” OM

Karen Appold is a medical writer in Lehigh Valley, Pa. Send comments to

Optometric Management, Volume: 48 , Issue: June 2013, page(s): 18 19