Medical vs. Vision Insurance
One of the most challenging billing issues in an ophthalmology office is whether we should be billing the medical or vision plan. Your medical insurance may cover a medical eye problem, but not pay for the exam if it is a "routine" eye exam. If you have a medical problem (infection, corneal disorders, diabetes, a lazy eye, cataracts, glaucoma suspect, dry eye, double vision, etc.), your visit is considered a medical problem and can be billed to your medical plan.
The Center for Eye Care and Optical participates in the following insurance plans. If you do not see your insurance plan below, please feel free to give a call to check if we accept your plan.
Many medical plans are no longer paying for eye exams because of a diagnosis of blurred vision or a headache. They are considering this a routine vision exam and are often not paying for the exam. Vision plans provide coverage for routine exams, glasses, and contact lenses, or at least give you some type of discount on the doctor’s fees. If you have trouble with your vision (nearsighted, farsighted, astigmatism, etc.), your visit is considered a vision problem and can be billed to your vision plan. Our billers will determine the appropriate plan (medical or vision) to file your claim, based on the results of your exam.
Routine vs. Medical Eye Exams
Office visits to an eye care professional are usually categorized as either "routine" or "medical". This terminology has nothing to do with the steps it takes to perform a comprehensive eye exam, or the type of doctor who performs the exam. A comprehensive "routine" vision exam often contains the same elements as a comprehensive "medical" eye exam, and seeing an ophthalmologist (MD) doesn't make the exam medical in nature.
The type of eye exam you have is determined by the reason for your visit or your chief complaint, as well as your diagnosis. Routine vision exams usually produce final diagnoses such as nearsightedness or astigmatism, while medical eye exams produce diagnoses such as "conjunctivitis." Most insurance companies focus on the reason for your visit.
Let's say your employer provides both types of insurance -- medical insurance as well as a separate vision plan, such as Vision Service Plan (VSP).
You decide that it's time for your annual eye exam because your glasses are falling apart. So you see your Optometrist (OD) for a routine eye exam and to purchase new glasses. Your doctor’s office authorizes your benefits so you proceed with the examination. At the end of the exam, your doctor informs you that in addition to a minor prescription change, he found signs of glaucoma. You are instructed to return in one week for additional tests.
Remember that your original reason for the visit had been to have an eye exam and to purchase new glasses. Even though your doctor found signs of glaucoma at the end of the examination, this visit would be covered under your "vision plan" because the main reason for the visit was to get your vision checked for new glasses. But, because at the end of that exam you are considered a potential glaucoma patient, your medical insurance will cover the additional tests and office visits related to the medical diagnosis of "glaucoma suspect."
You decide that it's time for your routine eye exam because your vision benefit has renewed and will allow you to have a routine exam and new glasses, but you also have an ongoing medical condition that the Ophthalmologist (MD) treats you for. In order for your vision benefit to cover the exam, you must specify that your reason for coming in is to have a routine exam and new glasses, and that you are under an Ophthalmologists care for your medical condition.
What happens if you have concerns about your eye health but you also need new glasses? Can you have your vision checked even though you have a medical eye problem? The answer, of course, is yes. However, your eye doctor may charge you a refraction fee. Medical insurance companies usually separate the components of an eye exam, one being the comprehensive exam and the other being the refraction. Typically, vision insurance policies usually cover both the eye exam and the refraction, while medical policies cover the exam only.
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