Insurance Won't Pay for Progressives

[beach57]

I have had progressive lenses (Hoya ECP) for several years. My optometrist always billed them as CPT code V2300 (trifocal lenses) and my insurance company (Carefirst Blue Cross Blue Shield of MD) always paid the claims. I switched to a new optometrist this year. His office used a different CPT code V2781 (progressive lenses) and the claim was rejected. Our insurance plan does not specifically cover progressive lenses. They cover single vision, bifocal, and trifocal lenses. My new optometrist will not resubmit the claim as trifocal lenses because he said it would be "insurance fraud." Aren't progressive lenses essentially no-line bifocals or trifocals? Varilux lenses have been around since the late 50's. Wouldn't you think my insurance company would be paying for them by now?? I think it is just a matter of how the claim is coded as to whether they will pay. They said if my optometrist agrees to provide additional information to them, then they will reconsider the claim. They said the code V2781 is "too generic." Any suggestions on how to get Blue Cross to pay this claim?

[For-Life]

I have had progressive lenses (Hoya ECP) for several years. My optometrist always billed them as CPT code V2300 (trifocal lenses) and my insurance company (Carefirst Blue Cross Blue Shield of MD) always paid the claims. I switched to a new optometrist this year. His office used a different CPT code V2781 (progressive lenses) and the claim was rejected. Our insurance plan does not specifically cover progressive lenses. They cover single vision, bifocal, and trifocal lenses. My new optometrist will not resubmit the claim as trifocal lenses because he said it would be "insurance fraud." Aren't progressive lenses essentially no-line bifocals or trifocals? Varilux lenses have been around since the late 50's. Wouldn't you think my insurance company would be paying for them by now?? I think it is just a matter of how the claim is coded as to whether they will pay. They said if my optometrist agrees to provide additional information to them, then they will reconsider the claim. They said the code V2781 is "too generic." Any suggestions on how to get Blue Cross to pay this claim?

Looks like you may have to do the running around. I would go into the kitchen cabinet, grab your insurance forms, get the numbers you need and call Blue Cross yourself.

It may only cover you for bifocals and you would pay the difference, but that is still better than paying for it all.

[beach57]

Looks like you may have to do the running around. I would go into the kitchen cabinet, grab your insurance forms, get the numbers you need and call Blue Cross yourself.

It may only cover you for bifocals and you would pay the difference, but that is still better than paying for it all.

Thanks for your suggestion. I was on the phone with Blue Cross THREE TIMES today, as well as the optometrist's office. All that Blue Cross could tell me was that they don't specifically cover progressives. However, the person at Blue Cross didn't even know what a progressive lens was. You would think that the people answering the phone for vision benefits would at least be familiar with such a basic product as a progressive lens. I find it hard to believe that all the people with no-line bifocals don't have coverage with our plan. This plan is for State of Maryland employees, so it's has thousands of customers. I think my optometrist is not providing the correct CPT code for it to be covered. Blue Cross wouldn't tell me how it had to be coded to be covered.

My insurance provides a $101 reimbursement for trifocal lenses. They won't pay a single penny to me as it stands right now. It seems to me they should at least pay for the trifocals (since I assume they are less expensive than the Varilux panamic lenses I got.) Seems that progressive lenses sort of fall in a greay area on our insurance plan. We have the most expensive and comprehensive plan that they offer. I'm just sick that they won't pay and that the optometrist thinks he would be committing insurance fraud. I spoke with the person who handles the insurance for my old optometrist. She said they always code the progressives as bifocals or trifocals and that it is an accepted practice and not insurance fraud.

[chip anderson]

First if you have found a way to get money out of BC/BS without pestering them to death repeatedly. Please let me know. They seem to be in the business of not paying claims. They will deny claims for you following thier advise. I could go on here for hours.


When are you people going to learn: "Insurance does not pay for anything." "The Government does not pay for anything."
The policy holder or the taxpayer pays for everything plus the cost of administration and sales.

Don't take out policies on small optional items. Have insureance for catastrophic, medical and liabilties only.

Chip

[Fezz]

Well, well, well...Welcome to the H*ll known as managed care!! I think that most of us here on Optiboard can understand your frustration. But, imagine our frustration with having to deal with the nightmare day in, day out, 365 days a year. You now have a taste of the garbage that the medical field goes thru. You mentioned that you have the most expensive and comprehensive plan...SO WHAT!!!!!!!! That really means nothing! KNOW YOUR PLAN. Why did you leave your old Optometrist? And why would you then call his/her office and waste the time of the employees there(that the poor Optometrist had to pay while you bothered them)? Then you have the nerve to bug us and drag us in...PAY YOUR BILL! I am truly stunned when I hear of something like that :angry:


Fezz
:cheers:

[beach57]

Well, well, well...Welcome to the H*ll known as managed care!! I think that most of us here on Optiboard can understand your frustration. But, imagine our frustration with having to deal with the nightmare day in, day out, 365 days a year. You now have a taste of the garbage that the medical field goes thru. You mentioned that you have the most expensive and comprehensive plan...SO WHAT!!!!!!!! That really means nothing! KNOW YOUR PLAN. Why did you leave your old Optometrist? And why would you then call his/her office and waste the time of the employees there(that the poor Optometrist had to pay while you bothered them)? Then you have the nerve to bug us and drag us in...PAY YOUR BILL! I am truly stunned when I hear of something like that :angry:


Fezz
:cheers:

I changed optometrists because we moved. I didn't think I had to justify my reasons in order to get an answer. I thought that my plan covered progressive lenses because our claims had never been denied over the past five years. Then when I switch to a new optometrist, they are suddenly denied due to a difference of opinion as to how the claim should be coded.

I can understand that eye care professionals can be very frustrated having to deal with insurance companies on a daily basis. It can be equally as frustrating for the patients also. Don't worry, I've already paid my $747 bill for my new frames and lenses. I had to pay it at the time I placed my order. I was just hoping to recoup $100 for the lenses from my insurance company.

I never expected to receive such a hostile response. I thought I might get some suggestions from the members of this message board. I guess I was wrong. Hopefully, all the other members are not as bitter as you appear to be.

[beach57]

I still can't get over paying $747 for one pair of glasses! It's truly outrageous how high the markup is on lenses and frames. I hope you don't expect me to feel sorry for my "poor" optometrist.

[Jubilee]

Most insurance plans will allow the office to bill for standard BIFOCALS and the list the "upcharge" for the difference in price.

There is some arguement about billing for bifocals or trifocals. Some plans state that the progressive lenses are about cosmetics, and therefor will only allow billing for a bifocal.

Others state that since there is three distinct zones in the lens, a trifocal code was valid.

This is something only the insurance company can decide.

Ask to speak to one of the supervisors at the insurance company, or better yet.. talk to your HR person and have them get the answer for you.

Cassandra

[beach57]

Most insurance plans will allow the office to bill for standard BIFOCALS and the list the "upcharge" for the difference in price.

There is some arguement about billing for bifocals or trifocals. Some plans state that the progressive lenses are about cosmetics, and therefor will only allow billing for a bifocal.

Others state that since there is three distinct zones in the lens, a trifocal code was valid.

This is something only the insurance company can decide.

Ask to speak to one of the supervisors at the insurance company, or better yet.. talk to your HR person and have them get the answer for you.

Cassandra

Thank you so VERY MUCH for your useful and constructive advice. I understand the debate between bifocals and trifocals. But my optometrist is NOT willing to bill my new Varilux panoramic lenses as either. He says the reason he won't bill as bifocals or trifocals is because it would be insurance fraud. Therefore, I'm getting no reimbursement whatsoever from BC/BS. Isn't it customary to bill progressive lenses as either bifocal or trifocal? I hate to suggest this, but is it possible that he makes more profit if the claim is rejected by BC/BS?

I will call BC/BS tomorrow and request to speak to a supervisor. I really would like to get to the bottom of this run around. I already spoke to someone in HR and she said other employees had been reimbursed for progressive lenses.

[n711]

what you are going through people go through every single day...NO ins company will pay for progressive lenses...most offices (all I've ever worked at ) will bill the ins for the "base" lens (either a bifocal or trifocal) so the ins pays towards that and the "progressive add on" is going to be out of pocket no matter what...Now to address you $747 glasses....that is a very standard price for delux lenses (progressives) with a new frame...and I asume you also have an anti-reflective coating.....To address you comment to the mark up these lenses and your "poor" optometrist.Mark up is A LOT LESS than you think...or us "poor" opticians would make more:o

[chip anderson]

Isn't it illegal, fraudulant and unethical (sorry for ancient defunct term here) to bill the insureance company (or anyone) for something you did not furnish or the patient didn't recieve (bifocals or trifocals in this incidence). Why not just bill for retinal surgery or something since the insureance company won't pay for progressives? There's some real money to be had in billing for surgery not preformed why limit it to bifocal lenses?

Chip

[eyegoddess1028]

jeez....your old optometrist was also probably loosing $ too. The insurance company will only repay the provider a set amount that was contracted with them. guess what, a frame that cost $5 or $900 the provider will get the same reimbursement. Insurance companies are only going to pay for basic things (think of dental, invisible braces will not be covered vs regular braces but they both do the same function right?) most insurances i come in counter with aren't even worth paying for. you buy glasses every 1-2 years, maybe even 2 pairs. You hit a good sale with a REPUTABLE chain or private office spend $300 after all your enhancements and you have actually saved $. vs paying $150 for all your co pays plus that $10 deduction every week out of your pay check =150+520=$670.

yeah you had a good thing @ your last dr, but sorry you had to hit the real world. my advice, see if you can drop the vision coverage (unless it's medically neccessary then you could file a grievence and wait 2 months for reimbursement)

[eyegoddess1028]

ps last year a major plastic surgery office got in HOT water for billing insurance company wrong procedures so people could get their tummy tucks paid for (they were billing for things like colonoscopy but performing rhinoplasty)

[eyegoddess1028]

ps last year a major plastic surgery office got in HOT water for billing insurance company wrong procedures so people could get their tummy tucks paid for (they were billing for things like colonoscopy but performing rhinoplasty)

[orangezero]

I'm new to all this, but there is a difference between standard practice of vision insurance (which covers routine exams and some basic frames and lenses) and medical insurance. Definitely billing the wrong thing for medical insurance would be fraudulent, not sure about standard business practices of vision insurances with upcharging like that. I'm amazed they dont' have a disclaimer in their policy though, since most nowadays want progressives.

[fjpod]

There is just a mis-communication going on here between the optical plan and the provider and somebody needs to straighten it out. It is well understood in the industry (optical insurance) that progressives are not fully reimbursed. Part of the problem is that many optical plans do not follow a national standard for coding. The benefit is based on what the employer wants to cover for their employee, and the plans can have varied ways in which they want to be billed.

It is not fraud to bill for a bifocal or trifocal if that is the highest level of benefit that the plan will allow when the patient gets a progressive. It is simply a request by the provider, on behalf of the consumer, for the appropriate benefit to which he/she is entitled. It has nothing to do with ethics. It's a matter of speaking the same language.

[Jubilee]

Well Chip,

While I can not speak for all plans, I know it tells me in my provider book for Medicaid that I can let a patient of theirs get a progressive, and just charge them for the difference in price. Billing it in the same manner as VSP where you list the appropriate Bifocal Vcode and your standard price, and then a Progressive code with the upgrade. They will not reimburse for the upcharge, but they will for the bifocal.

This is the way our office and many others have been doing this for years, and we have passed a financial audit from state and VSP.

MY former employer (LC) filed in this manner too for plans that didn't cover progressives directly as well.

Cassandra

[Jubilee]

I still can't get over paying $747 for one pair of glasses! It's truly outrageous how high the markup is on lenses and frames. I hope you don't expect me to feel sorry for my "poor" optometrist.

Do you feel that those who spent THOUSANDS of dollars to get a very specialized education are entitiled to charge for that education and service they provide for it?

There is more to prpviding a quality eye exam and glasses than "which is better, one or two," a frame, and a couple of lenses.

Things that are factored into the cost of a pair of lenses:

Education (for ALL of staff)
Expertise
Staff time (not only for dealing with your specifically, but for after the visit filing insurance, buying frame, clean up, etc)
Rent or Bank Payment for space/building
The Dr's Chair
Phoropter
Slit Lamp
Trial lens set
Auto-Refractor
NCT, TonoPen or whatever method for Glaucoma testing
Visual Fields machines
Ophthalmascope
Photography (if your doctor offers it)
Dispensing tables, mirrors, other decor
Computer systems
Lensometers
Lab Fees (which are higher than you think)
*In the LABS (in office if avoiding or limiting lab fees)
Generators
Edgers
Groovers
Tinting equipment
Special Plumbing & Electric hookups
Coating units
And more..

In fact I don't have time to list them ALL.. Since I need to be at work in 15 and have to leave for work now..

But there is a heck of a lot more that goes into determing a price for frame and lens than just their costs.

Cause if we didn't charge enough to cover the rest of the bills. We would be bankrupt in a year.

Cassandra

[beach57]

jeez....your old optometrist was also probably loosing $ too. The insurance company will only repay the provider a set amount that was contracted with them. guess what, a frame that cost $5 or $900 the provider will get the same reimbursement. Insurance companies are only going to pay for basic things (think of dental, invisible braces will not be covered vs regular braces but they both do the same function right?) most insurances i come in counter with aren't even worth paying for. you buy glasses every 1-2 years, maybe even 2 pairs. You hit a good sale with a REPUTABLE chain or private office spend $300 after all your enhancements and you have actually saved $. vs paying $150 for all your co pays plus that $10 deduction every week out of your pay check =150+520=$670.

yeah you had a good thing @ your last dr, but sorry you had to hit the real world. my advice, see if you can drop the vision coverage (unless it's medically neccessary then you could file a grievence and wait 2 months for reimbursement)

You mention a $10 week deduction from my paycheck for insurance. My BC/BS plan costs our family $1.50 per week. So our vision plan costs us $78 per year. For that, all three of us each get reimbursed $36 for eye exams, $100 for progressive lenses (husband and myself), $97 for contact lenses (daughter), and $45 for frames. That comes to a total of $540 in vision benefits for a $78/year premium. I don't think that is a bad investment of our money. I'm just frustrated that my optometrist won't bill my progressive lenses properly so I can get reimbursed as I have in the past.

[AWTECH]

That comes to a total of $540 in vision benefits for a $78/year premium. I don't think that is a bad investment of our money. I'm just frustrated that my optometrist won't bill my progressive lenses properly so I can get reimbursed as I have in the past.

This sounds like the line: "I went shopping at the mall all day and saved $500.00". (Unfortunately the checking account is now $2,000.00 less)

Did you really save? Does your eyecare provider write you a check for $540?

Insurance companies are not in the business to loose a little on every transaction and make it up in volume. They are in the business to charge more in premiums than they pay out in benefits.

[GOS_Queen]

The claim IS what it IS now ~ arguing with the billing staff is not the way to get it resolved. They billed it they way they feel is best.

So now, I would recommend:
1) talk to a supervisor at your insurance company.

2) have THEM contact someone in the billing office ~ sometimes, hearing the request from the insurance company has more merit than a patient/consumer.

For example, in the billing office I work at, I get asked by patients to "change the diagnosis code from routine to medical or from medical to routine" just so the insurance will pay. I will listen empathetically to the patient and I will pose the question to the DR but often, "it is, what it is".

However, when I have a request from someone in the patient's insurance company, I am more apt to take the request more seriously. If the insurance company requests a "corrected claim" with the Vcodes they will pay, I can't imagine the DR's office will say "no" (YMMV).

3) After the matter gets resolved, if you still feel "wronged", then by all means, right a letter to your new DR AND your insurance company and explain, in writing, your frustration. If you like, you can also "copy" the letter to your employer's HR dept, State Attorney General's office, insurance regulatory board etc. You, as a consumer of these goods, have the right to voice your opinion and dissatisifaction.

Unfortunately, the insurance system is so crazy ~ the situation you described is really the tip of the iceberg.

HTH -

[Karenrp1956]

According to what you wrote "100 for progressive lenses", they should pay for progressive lenses, or is this a misquote. Filing for a trifocal for a progressive is not fraud. I agree, call and talk to a supervisor, they should help you.

You mention a $10 week deduction from my paycheck for insurance. My BC/BS plan costs our family $1.50 per week. So our vision plan costs us $78 per year. For that, all three of us each get reimbursed $36 for eye exams, $100 for progressive lenses (husband and myself), $97 for contact lenses (daughter), and $45 for frames. That comes to a total of $540 in vision benefits for a $78/year premium. I don't think that is a bad investment of our money. I'm just frustrated that my optometrist won't bill my progressive lenses properly so I can get reimbursed as I have in the past.

[beach57]

My insurance problem has been resolved. A very helpful customer service rep from BC/BS called my optometrist regarding my claim. They worked out the disagreement regarding the billing codes and I will now receive a $100 reimbursement for my new progressive lenses.

I want to thank all the people on this message board who were helpful and provided constructive advice for me.

[beach57]

There is just a mis-communication going on here between the optical plan and the provider and somebody needs to straighten it out. It is well understood in the industry (optical insurance) that progressives are not fully reimbursed. Part of the problem is that many optical plans do not follow a national standard for coding. The benefit is based on what the employer wants to cover for their employee, and the plans can have varied ways in which they want to be billed.

It is not fraud to bill for a bifocal or trifocal if that is the highest level of benefit that the plan will allow when the patient gets a progressive. It is simply a request by the provider, on behalf of the consumer, for the appropriate benefit to which he/she is entitled. It has nothing to do with ethics. It's a matter of speaking the same language.

I want to personally thank you for your response to my question. I believe your answer was absolutely correct and helped me to successfully resolve this problem.

[fjpod]

I want to personally thank you for your response to my question. I believe your answer was absolutely correct and helped me to successfully resolve this problem.

You're welcome.