Medical vs. vision insurance: a billing guide for optometry practices

Optometry practices are unusual in that many patients carry two kinds of coverage for their eyes: a vision plan for routine care and medical insurance for eye disease and symptoms. Billing the wrong one leads to denials, write-offs and confused patients. Getting it right starts with understanding what each plan is for.

What vision plans cover

Vision plans are designed for routine, preventive eye care: a yearly eye exam, the refraction to determine a glasses or contact lens prescription, and allowances toward eyewear. They generally don’t cover the diagnosis or management of eye disease.

What medical insurance covers

Medical insurance applies when the visit is about a medical problem or symptom, such as eye pain, redness, flashes and floaters, dry eye, infections, injuries, or monitoring conditions like glaucoma, cataracts or diabetic eye disease. These visits are billed with medical diagnosis codes and the appropriate eye exam or evaluation and management codes.

The chief complaint decides

The reason for the visit, as documented in the chief complaint, usually determines which plan to bill. A patient who comes in for new glasses is a routine vision visit. A patient who comes in because of blurry vision from diabetes, or an eye that has been red and painful for three days, is a medical visit, even if they also have a vision plan.

Watch out for refraction

Refraction is often not covered by medical plans. Medicare, for example, does not cover routine refraction. Let patients know in advance when they may be responsible for that portion, and use the proper advance notice forms for Medicare patients when required.

Front-desk tips that prevent denials

• Collect both cards, vision and medical, at every visit and keep them current.
• Ask the reason for the visit when scheduling so the right plan is verified ahead of time.
• Verify benefits for both plans, including frequency limits on routine exams.
• Explain costs upfront for services a plan may not cover, like refraction or contact lens fittings.
• Document thoroughly so the record supports the codes billed to medical insurance.