Optometrists are primary eye care providers who perform routine and comprehensive medical eye services. Routine/wellness services screen for undiagnosed eye disease and determine a prescription for glasses. Medical services address more complicated eye health issues, not related to your glasses prescription.
One of the most challenging billing issues in an optometrist’s office is whether we should be billing the medical insurance or vision plan (if you have either). We do not make these rules and guidelines. As providers on your vision and medical panels we have to follow the rules set forth by them. Our staff, however, will attempt to verify both vision and medical insurance coverage prior to your visit.
Insurances – Medical vs Vision
For patient with BOTH medical insurance and vision benefits
Eye exam benefits provided by a vision carrier (EyeMed, VSP,…etc.) is intended to provide an exam to determine your glasses and/or contact lens prescription and screen for eye disease. In other words, vision insurance provides a routine eye exam benefit. It is similar to an annual wellness visit with your primary care doctor when you have no complaints.
If you are being evaluated for medical reasons (corneal disorders, red eye, diabetes, cataracts, glaucoma suspect, double vision, blurred vision, etc.), you are being provided medical eye care. Vision plans do not reimburse for medical eye care. Therefore, we will file a claim with your medical insurance for visits related to medical complaints and/or problems. If we are a participating provider with your vision plan, your exam will be filed as a secondary claim to your vision plan after your medical carrier processes the claim.
For patient with ONLY medical insurance and NO vision benefits
If you are being seen for a routine eye exam (you have no complaints and/or relevant history) and do not have vision benefits, your medical insurance will not pay for the exam. It is a non-covered service. Some medical insurance plans may have “routine vision” coverage. If this is the case, then we will bill the routine visit to your medical insurance. If your visit is for a routine eye evaluation, we collect the total regular exam fee at the time of service. However, if you have a medical problem (corneal disorders, red eye, diabetes, a lazy eye, cataracts, glaucoma suspect, double vision, blurred vision, etc.), your visit is considered a medical exam and will be billed to your medical plan. In these cases we will collect your medical specialist office visit copay, deductible, and/or co-insurance and submit the claim to your insurnace who will then determine if you owe any additional amount based on your specific plan.
For patients with ONLY vision benefits and NO medical insurance
If you are being seen for a routine eye exam (you have no complaints and/or relevant history) and have vision benefits then your vision insurance will be billed for the services. We will collect the appropriate copays on the day of service. However, if you have a medical problem (corneal disorders, red eye, diabetes, a lazy eye, cataracts, glaucoma suspect, double vision, blurred vision, etc.), your visit is considered a medical exam and cannot be billed to your vision plan. You will be responsible for the full amount of the exam. We will always talk with you about your options before performing additional diagnostic testing. Some vision plans offer primary eye care benefits for medical eye exams. In those cases you will be responsible for the applicable co-pays.