Article

EXPLAINING BENEFITS

Q: How can I explain benefits to patients; for example, the difference between vision and medical insurance?

A: Before I answer, I feel it’s important to explain the reasons the question needs to be asked.

REASONS BEHIND THE QUESTION

The crux of the issue lies in the burden of financial responsibility on the patient, the incongruence in reimbursement schedules and the patient’s perception of what he was sold when purchasing his vision insurance: Many times, there is no difference between vision insurance and medical insurance in the mind of the patient. The essence of this problem lies in the delineation of benefits, which, of course, are finite and limited by the vision insurance. Specifically, vision insurance may provide coverage for annual comprehensive eye health evaluations and the need for refractive correction, such as glasses and contact lenses.

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The second issue lies in the relentless increase of deductibles being imposed upon the subscriber, or a patient, by the medical insurance, due to escalating premium costs. The average deductible for employer sponsored health care plans amounted to $1,491 with single coverage and $2,788 with family coverage, according to a 2018 survey by the International Foundation of Employee Benefit Plans. Employees in a high-deductible health plan (HDHP) have an average deductible of more than double that of a non-HDHP plan: $2,296 for single coverage and $4,104 for family coverage, according to the survey. Of course, deductibles and copays can vary greatly from plan to plan and state to state. Additionally, greater than four in 10 employees enrolled in a high-deductible plan say they don’t have enough savings to cover their deductibles, according to a recent nationwide poll conducted by The Los Angeles Times, in conjunction with the Kaiser Family Foundation, the Health Care Cost Institute and the Employee Benefit Research Institute. Further, one in six Americans who have employer-offered health care report they’ve had to cut back on food, move in with friends or family or take on extra jobs to afford their healthcare. And so it’s not difficult to understand why shifting from vision insurance to medical insurance makes for an unsavory proposition. The provider may feel squeezed by the cost of delivering what he believes is necessary and appropriate care for the patient and the reimbursement for services rendered. These forces create the dilemma and call into question, “Who should I bill: the vision insurance, the medical insurance or the patient?”

Of course, everyone in the industry is aware of these issues, and I’m sure they are seeing through my thinly veiled attempt at procrastination in delivering what will be a highly debatable answer to a straight-forward question. So, my sincerest apologies to anyone I offend or who disagrees with my approach. I don’t believe there is only one right answer to this question.

THE ANSWER

My answer to this question is in the following tips. That said, these tips are not confined strictly to patient education regarding medical insurance and vision insurance, because how optometrists communicate the difference between them is often dependent on our understanding of — and attitude toward — a particular plan.

  1. O.D.s should truly understand the provisions of any vision insurance they agree to join. If they cannot justify the care required for the reimbursement offered, they shouldn’t join the insurance.
  2. If the optometrist joins, he should agree to accept the reimbursement offered and stop worrying about it because he agreed to the contract.
  3. O.D.s should deliver the care. In our practice, when a patient was discovered to have a pathological issue requiring treatment other than a refractive solution, we still allowed the patient to use his vision insurance, due to the right to receive a complete diagnostic protocol for the problem. (We billed the vision insurance for the visit and didn’t worry that, although maybe, we could have billed the patient’s medical insurance for the visit.) If medical procedures outside what were covered by the vision insurance were required, we explained the situation to the patient and billed the medical insurance for the procedure. Careful documentation, along with “proper ordering” of the test or tests, including the interpretation and report, should be addressed.
  4. Once a medical issue was discovered and deemed to require further intervention, we explained to the patient that we would bill his medical insurance going forward for any procedures or office visits associated with the medical issue.
  5. We still allowed the patient to use his vision insurance benefit at whatever interval was allowed by the insurance. We did not water down or otherwise alter our examination based upon reimbursement. (For additional information on this topic, visit see “Differentiate Insurance,” at bit.ly/DifferentiateInsurance .). OM