Many patients in the United States have dual insurance coverage for eye care. In fact, five out of 10 patients are covered under a vision plan, while seven out of 10 are covered under medical insurance.1,2 Some other medical specialties are limited to billing for office visits, but the practice of modern optometry provides a powerful opportunity to take an initial patient encounter for vision care, glasses, or contact lenses and create additional future encounters, thereby maximizing that patient’s lifetime engagement with your practice.
A COMMON SCENARIO
Let’s say you have a patient in your chair for a vision exam for new glasses or contact lenses, and upon performing the ocular health examination you detect a medical eye condition. Rather than pushing the eject button and referring the patient, optometrists need to embrace our broad scope of practice (dependent on locale) that allows us to offer our patients a full continuum of care.
Offering that full continuum requires us to make some decisions. Do we flip the initial vision exam to a medical encounter for the higher reimbursement and address the patient’s medical needs first? This option requires that the patient be educated on his or her medical insurance coverage, deductibles, and copays, which may differ from what he or she had initially expected. The other option is to proceed with the vision examination to produce a prescription so that the patient can purchase glasses or contact lenses that same day, then educate him or her on the need for additional testing and schedule a follow-up visit for a problem-focused battery of tests.
Modern optometrists choose between these options many times every day. We challenge you to consider this an opportunity to maximize each patient encounter.
How encounters are maximized is a matter of doctor preference and office protocol. By clearly understanding the nuances of coordinating benefits and leveraging internal referrals, you can unlock the path to subsequent encounters to provide comprehensive eye health and vision care for patients while also maximizing your practice’s performance.
As owners of our own medically oriented optometric practices, we are committed to offering a full continuum of care for our patients, up to and including ophthalmology and in-house surgical services. However, our approaches differ, as we describe below.
Dr. Murphy’s practice model is to almost always focus on medical first. She uses the initial patient encounter to address medical needs and bill the higher reimbursing medical insurance, while also coordinating benefits with the patient’s vision plan.
(Note: All vision plans are not created equal. For example, VSP Vision Care allows and promotes simultaneous billing of both the patient’s vision plan and medical insurance for different components of the same encounter.)
Specifically, coordination of benefits allows the billing of the office visit and any procedures performed to medical insurance, while VSP is billed separately for the refraction (up to an allowable amount) and materials benefits.
Under another scenario, if all of the required components of a 92014 encounter (medical evaluation, comprehensive, established patient) are performed, Dr. Murphy’s office bills medical insurance with both the medical diagnosis and the refractive diagnosis. If the patient still has a deductible at the time of the encounter, the office bills VSP (see specific details in VSP’s Provider Reference Manual) and applies the payment toward the medical insurance deductible or copay, then balance bills the patient for the remainder of the deductible up to the cost of the services rendered.
A 35-year-old patient enrolled in a VSP plan comes in for a contact lens prescription update. The patient reports that his current lenses are intolerable because his previously diagnosed ocular and systemic allergies have been extremely bothersome, causing tearing, itching, and red eyes.
This patient’s treatment plan would consist of the following steps:
- Perform refraction and provide glasses prescription to reduce contact lens wear. Refit patient with daily disposable contact lenses.
- Diagnose patient’s allergic conjunctivitis condition status (poorly controlled), educate him regarding allergen avoidance and other factors, and initiate treatment (medication, reduced contact lens wear).
- Perform dilation to complete a comprehensive eye health evaluation.
- Recommend that the patient return to the clinic for a follow-up office visit to determine the state of his allergic conjunctivitis and contact lens success.
This encounter would be billed to medical insurance. Any copay or applicable deductible would be billed to VSP, along with the refraction and the contact lens fitting. Often, patients have a higher medical insurance copay but are pleased to know that their vision insurance can be used to offset that copay, thereby allowing them to maximize their benefits. The patient’s next visit related to the state of his allergic conjunctivitis would be billed to his medical insurance. If the condition resolves but additional visits are necessary to finalize the contact lens prescription, such visits would be included in the initial contact lens fitting billed to VSP.
Dr. Chu uses the initial vision examination visit to produce a prescription and capture the glasses and contact lens material sales. Although he tries to maintain this visit as a vision exam billed to the vision plan, this consultation also more importantly serves as a springboard for the doctor and patient to work together on a long-range treatment plan, including subsequent visits and referrals to other doctors within the practice who specialize in areas of expertise to address the patient’s comprehensive eye care needs. All subsequent visits are then billed to medical insurance.
A 58-year-old patient covered by a VSP plan comes in to update her glasses. The comprehensive examination reveals a prescription change, along with dry eyes, mild cataracts with glare, ptosis, and elevated IOPs. A family history of glaucoma was noted in the patient’s history.
This patient’s treatment plan would consist of the following steps:
- Prescribe new glasses, which are covered by vision plan and overages.
- Have the patient return to the clinic for a dry eye workup and temporary punctal plugs, both of which are billed to medical insurance.
- Refer the patient to a cataract surgeon for evaluation and schedule the appointment at this visit.
- The patient qualifies for cataract surgery and proceeds with surgery.
- The patient’s prescription changes after cataract surgery. Glasses remake is covered by the vision plan at no charge to the patient.
- Refer the patient to an oculoplastic surgeon for blepharoplasty after cataract surgery.
- Because the patient is a glaucoma suspect, he is instructed to return to the clinic for a glaucoma workup at the same visit as his dry eye workup. This workup is also billed to medical insurance.
DIFFERENT ROUTES, SAME GOAL
Although we differ in our initial sequencing for handling our patients’ eye care needs, we agree that, if done properly, coordinating a patient’s benefits can unlock a powerful tool for helping them to obtain and afford the eye care they need.
The key is the initial vision encounter because it can lead to a multitude of subsequent appropriate encounters and referrals to solve the patient’s eye care needs. Properly and efficiently coordinating vision care and medical eye care is what sets modern ODs apart from our predecessors.
Both vision plans and medical insurance coverage operate in highly fluid environments. With shifting demographics and changing government regulations, it’s always important to be looking ahead.
Some Medicare supplemental plans are now offering vision coverage, and some vision plans have developed new materials-only benefits to accompany office eye care visits covered by Medicare. Under these plans, the vision plan connects Medicare patients to our practices. If a medical diagnosis exists, the encounter can be billed to Medicare and the materials can still be billed to the vision plan. Medicare patients also tend to present with other downstream medical eye needs.
Based on industry trends such as these, we believe that there will be stronger synergies between vision plans and medical insurance plans in the future. Learning how to coordinate benefits will help to differentiate top doctors and fully optimized practices from the rest of the pack. Once you experience the growth that coordinating vision and medical insurance can bring, you will know you did the right thing for your patients and for your practice.
1. Managed vision care and behavior report. The Vision Council. www.thevisioncouncil.org/members/managed-vision-care-and-behavior-report. Accessed August 20, 2019.
2. Health insurance coverage in the United States: 2017. United States Census Bureau. September 12, 2018. www.census.gov/library/publications/2018/demo/p60-264.html. Accessed August 20, 2019.