Medical Exam vs Vision Exam

[lucymarie]

Wondering how various offices handle billing for medical exams with refractions? Do you allow the patient to use their vision benefits at the same time to cover the refraction portion of the exam or do you have them return for a separate visit? Are there times you do not know the patient has the vision plan until long after the medical exam and the refraction is now being billed self pay to the patient because the medical didn't cover it? Do you allow them to use the vision plan at that time?

[drk]

There's no hard/fast rule, just a handful of scenarios. Some of it depends on the patient's expectations, some on their problem.

1. In general, if it's a medically necessary exam, refraction is not covered by the medical insurer. Medicare is hard and fast on this rule.
2. Exceptions are cataracts, and maybe other diagnoses. Many commercial insurers will pay for refraction with a cataract diagnosis, because it's needed to make the diagnosis. I wouldn't get to excited about this.
3. If it's a routine exam with refraction, some medical plans will pay for routine services. Most don't.
4. If the patient has a vision plan as well, one has to be primary and one has to be secondary. If it's a medical visit, the medical is primary. The copays and deductable and non-covered services can be submitted to some vision care plans for reimbursement up to a plan maximum via a semi-arduous process. VSP does this. EyeMed claims to, as well.
5. You can't just submit a claim for refraction only directly to VSP and EyeMed. They vehemently wish to deny this kind of service, and I have no idea why. You have to submit to the primary medical carrier first, get denial on the refraction, and submit.
6. Vision care plans make you do a routine exam to get paid. You can't just do a refraction and submit to them for that, ever, no matter what.

[TLG]

I work in an Ophthalmology practice. Since our docs are MDs, with a routine exam patients are able to use their medical insurance to pay for the medical part of the exam, paying whatever their copay is. We then charge them an additional fee for the refraction. If it's a vision plan - VSP, Eyemed etc - the entire exam is covered with their copay.

drk, regarding your #4 - Doesn't VSP always require that they be the primary if you're billing them?

[harry888]

If you bill medical instead of Vision, the medical may go towards the deductible.

then there is hell to pay from the patient who knows they get the yearly exam with minimal copay.

Harry

[Jubilee]

VSP does not require themselves to be primary when doing COB with a medical plan. Eyemed and Davis vision also will do COB with a medical plan. All require paper claims and copy of EOB w/claim.

[David_Garza]

VSP does not require themselves to be primary when doing COB with a medical plan. Eyemed and Davis vision also will do COB with a medical plan. All require paper claims and copy of EOB w/claim.

We don't work with Davis and VSP COB is pretty simple, but in my experience EyeMed (E/M) claims are not reimbursed with COB. Usually with HVCP and E/M we tell the patient their VCP does not allow us to COB their Medical and VCP claims on the same day. For these 2 VCPs we usually always do the medical first followed by the routine/refraction exam on another day.