Coding and Billing

2 Reasons NOT to Agree to Charge a Patient’s Vision Vs. Medical Insurance

By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD

Dec. 2, 2020

Patients may sometimes request that you charge their vision plan, rather than their medical insurance, to allow for cost savings when they have a medical eye problem. Here are two important reasons not to do that, and what you should do instead.

REASON #1: Follow the rules you’ve agreed to follow.
When you signed up to be a provider for every carrier – vision and medical – you agreed to follow their rules. Since you agreed to follow their rules, they will hold you to that agreement.

One of the agreements you made is that medical eye related problems should be billed to medical insurance carriers and non-medical eye exams should be billed to vision plan carriers (there are exceptions). VSP says on its web site, “Most vision plans provide access to preventative eye exams and corrective eyewear. Your regular health insurance plan may cover health costs if you injure your eyes in an accident or have a health condition that affects your vision.”i Medicare says on its web site, “Medicare doesn’t cover eye exams (sometimes called “eye refractions”) for eyeglasses or contact lenses.”ii Follow the rules and do the right thing.

REASON #2: Be the doctor – don’t let patients talk you into wrong actions.
It is your responsibility to know the rules and to communicate those to your staff.

The question becomes: is billing a vision exam when a medical exam would have been the correct call bad? Let’s put it another way – in this case, you are attempting to get money from a company when it is not the right thing to do. Fraud is defined as “intentional perversion of truth in order to induce another to part with something of value …”iii If you are attempting to get money from a vision plan when a medical carrier should have been billed, this action is fraudulent.

You would think the issue is clear when the patient seeks an eye exam for a red eye. A red eye is a medical condition that should be billed to the medical carrier. Be aware that some vision plans have medical plans that cover red eyes. You and your staff need to knows these exceptions.

Consider the situation where the patient wants new glasses and their annual eye exam covered by a vision plan, but during the eye exam you discover glaucoma. Glaucoma is a medical condition. Since the reason for the visit determines medical coverage, and the reason for the visit for this exam was that the patient wanted new glasses, this exam should be billed to the vision plan. Any additional exams addressing the glaucoma should be billed to the medical carrier.

How do you handle the demanding patient?
The best way to handle this situation is to identify the reason for the examination when the patient schedules the examination and discuss payment at that time. When the patient says “I have a red eye” and my payment method is my vision plan, your staff member needs to be trained when to say to the patient that because the patient has a medical condition, the payment will be under the patient’s medical plan. This means your staff needs to understand vision coverage (and when it covers medical conditions), as well as medical insurance coverage. The wrong place to have this discussion is at the front desk or at check-out.

References
i. https://www.vspdirect.com/faq/vision-plan-coverage/medical-coverage
ii. https://www.medicare.gov/coverage/eye-exams-routine
iii. https://www.merriam-webster.com/dictionary/fraud

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