The term “medical model” is used quite often among optometrists, but it can have different meanings to different people. To me, it means more than just providing medical eye care, which most optometrists do quite often. I use medical model to refer to billing medical insurance plans for a medical eye condition, even if the patient has vision plan benefits available. Most ODs are network providers for Medicare and medical insurance plans and we are increasingly billing these plans for services when appropriate. But patients are often confused about the difference between medical insurance and vision plans. Here are some tips on how and when to bill various insurance plans that cover eye health and vision care.
Is it legal to bill medical insurance if the patient has a vision plan? Certainly, as long as the patient had a chief complaint that was medical in nature and a medical diagnosis code. Vision plans clearly state that they provide coverage for routine vision care services and optical products.
Is it legal to bill a vision plan if the patient has a medical diagnosis? Vision plans will pay for a vision exam as long as the patient is eligible for benefits, which occurs based on a timetable, such as once per year. The vision plan would not reject a claim for patients who have medical eye problems; after all, they could also need a refraction and glasses at some point. But a vision plan is not the correct insurance for medical eye care and it is not a good practice to use it for that purpose. However, there is a gray area where the exam could technically result in a medical diagnosis, but the patient’s intent was to receive routine vision care. That is when the situation can get tricky. It is in the best interest of your practice to work on this gray area so you communicate well, educate patients and keep patient satisfaction high.
Should you bother with the medical model? Yes! Medical eye care is a more advanced level of service and you deserve to be paid at higher fees, which medical insurance typically pays. Many optometrists just bill the vision plan first in every case and if they need any additional testing, they would bill that to medical insurance. That is OK in those gray areas, but if the case is truly medical in nature, the exam should be billed to medical insurance. In my experience, the vast majority of patients with medical eye problems understand that their services should be billed to medical insurance and they are fine with it. There are some patients who don’t like it, but it is a minority and we can work with them to keep them happy.
How to present it to the patient. The best way to start is to give the patient a brief educational handout at check-in that explains the difference between vision plans and medical insurance (see Tip #561 for an example). Beyond that, the doctor or a clinical technician can just say to the patient at the end of the visit: “Mrs. Smith, your exam today will be billed to your medical insurance plan because you have a medical eye problem as the doctor discussed with you. We will save your vision plan and use it on a future visit and we can always use it for new eyeglasses. Judy at the front desk will go over all your charges with you.”
Use the vision plan at some point. The one factor in all this that vision plans feel strongly about is that the member (patient) should be allowed to use their vision plan at some point. That seems perfectly reasonable to me. The patient and his employer pay for that benefit and they have a right to use it. Whether you perform the routine exam and refraction first or later can depend on the case and the nature of the chief complaint.
Coordination of benefits (COB). This is an underutilized benefit that is available with some vision plans and with some limitations. If a vision plan allows COB, there will be section about it in the provider manual. COB is a great way to begin using the medical model because it limits the patient’s out-of-pocket expense. Basically, you bill the medical plan first with a medical diagnosis and you also bill the refraction. Some medical plans will cover the refraction, but most do not. The patient may also have a medical co-pay, which can be collected at the time of the visit or can be held on the patient’s personal account. If the medical insurance rejects the refraction, you may then use the COB procedure to bill the vision plan for the refraction and in some cases the plan will also cover the medical co-pay or part of the deductible.
Back to billing patients? There is no doubt that this trend to work with managed care causes us to have to send invoices and statements to patients. This seems counter-productive to optometrists who worked hard in the 1980s to eliminate the practice of billing patients. We got good at collecting the fees in the office. As we bill medical plans, we have to let go of this to some degree because we often find out later that a deductible was not met or some service is not covered. I’m happy to report that my practice has had very little bad debt as we transfer fees back to the patient and bill them. They generally pay quite well. Perhaps it is because they also receive the explanation of benefits from their insurance company and it shows clearly any amount that is owed to the physician. Perhaps the patients don’t want to have credit problems and they know they will need care in the future. At any rate, billing medical insurance has more pros than cons and we should embrace it.
Let the patient win. The most important lesson in the medical model is to keep the patient happy. The last thing I want to do is lose a patient and his family over which insurance plan we bill. Most patients are perfectly happy letting us bill the appropriate insurance for the care they receive, but if we have a patient who feels strongly about it, we let him have his way. Talk about the medical model and the gray areas at your next staff meeting.