Billing Question

**Audiyoda** · 10-13-2016, 12:10 PM

Hey Optiboard, it's been a long time.

Not so quick question I got from a friend who just saw a new Optometrist. He recently moved and found this OD through some people he works with.

My friend is diabetic and made the Optometrist's office aware when he made the appointment so they requested he bring both his vision and medical insurance information. After the routine exam (with dilation) he was told he owed $X for the copay. $X is the amount his medical insurance lists as the copay to see a specialist. The medical insurance lists $Y as the copay for a general office visit.

He called his insurer and the CS person he spoke with said that a OD billing medically should not collect the specialist copay unless he was seeing the OD under a referral for a specific need (ie... fitting contacts for keratoconus). I would agree with his insurer. The office manager at the OD's office refuses to refund the (substantial) difference between X and Y because (1) a dilation was done and (2) the chart shows the patient acknowledged he is diabetic and thus a check for diabetic retinopathy was performed.

I know for some this may be splitting hairs, but I'd like to hear opinions on the matter and reasons for/against how this was handled.

**buckeyeoptical** · 10-13-2016, 12:53 PM

Wait until they get the EOB from the insurance company. That'll tell exactly what should have been collected. Then the doctor should make it right.

**Audiyoda** · 10-13-2016, 04:01 PM

Already mentioned that to him. He said his insurer (BC/BS Anthem) isn't great on sending EOBs - that's why he was asking me what I thought.

**buckeyeoptical** · 10-13-2016, 06:17 PM

I can tell you that they are going to have a copay on a diabetic exam but Anthem probably will deny the refraction charge so the patient will have to pay that. Retina photos are about 50/50 but usually have a copay to. Just wait a couple months and call anthem and check the charges.

**Uilleann** · 10-14-2016, 10:50 AM

Every office I've ever worked in (Opto and Ophth both) have always medically billed as and been paid as a specialist when applicable for diabetic exams. Some of the manages care rackets (VSP et al) can now be billed for the diabetic exam as well, but in my experience, it isn't a "routine" visit - it's medical.