Vision vs Medical Insurance Guidelines for PMRG Clients

Patients with vision plans will sign a form at the time of service that explains that medical insurance may also be billed when necessary (Regarding Vision & Medical Insurance.)

Medical Exams:

All exams that include a medical diagnosis or medical testing on the same day will be billed to medical insurance.

VSP and MES Vision plans will coordinate benefits with the medical plan. The patient must have vision benefits available and an authorization must be obtained by the practice. All CPT codes with testing included will be billed to medical insurance first. After medical pays, the balance on the testing goes to the patient, and the remaining balance on exam and refraction will be billed to the vision plan. Patient may still owe a portion of the medical deductible after vision plan pays as explained in the patient form. If the vision plan was not presented at the time of service, we may still be able to coordinate benefits if a vision authorization can be obtained.

Vision Exams: 

All claims with only routine diagnosis codes will be billed to the vision insurance.

We cannot reverse medical claims and rebill vision plans because the patient wants their refraction covered or the exam has a deductible balance. Billing both insurances as primary is a fraudulent billing practice and could result in termination of your insurance contracts.

If the patient’s visit was billed medical and patient calls after the fact to provide vision insurance, we will apologize and reference the form that they signed at the time of service. This will help minimize the number of calls after the patient receives their statement or medical EOB. This will also reduce the number of tasks to the practice on how to handle these calls.

REGARDING VISION & MEDICAL INSURANCE PATIENT FORM:

We often have patients that have both vision insurance (for example, VSP or EyeMed) and medical insurance (for example, Blue Cross, Aetna, Blue Shield, or Medicare). They are very different in terms of the services they cover, and it’s important for our patients to understand these differences.

Vision insurance is designed mainly to cover determining a prescription for glasses, to help pay for glasses or contact lenses, and to cover a yearly routine evaluation of the health of the eyes in a healthy patient that has no particular problems or symptoms. It is not equipped to deal with and does not usually cover medical conditions, injuries, and/or treatments. Medical insurance is designed to cover you when you have a medical problem, including one that affects your eyes. Medical insurance does not cover routine services or examinations for glasses, or routine vision problems such as nearsightedness, farsightedness, and astigmatism. Those are only covered by your vision insurance.

When a medical diagnosis or medical condition is present that affects your eyes, such as high blood pressure, high cholesterol, or diabetes, to name just a few examples, or you have an eye disease or eye problem such as an infection (pink eye), dry eyes, allergy, or cataracts, again, just to name a few, we must file the claim with your medical insurance, and the co-pays and deductibles for that insurance will apply. Your vision plan does not cover these kinds of problems. Our office does not make these rules, they are made by the insurance companies themselves, and we must comply with them.

There is often no way to know prior to your examination which type of insurance will be the right one to file your claim with. We make every effort to join as many insurance panels—both medical and vision—as we can for your convenience. If we are on your insurance company’s panel, we will file those claims for you. In the event that we do not accept your medical or vision insurance, we will provide you with an itemized receipt so that you may file a claim for reimbursement with your insurance company yourself. If you have any questions, please let us know.

I understand the information above regarding the difference between vision and medical insurance. I authorize ___________________ to file my claim with the appropriate insurance based on the reason for my visit and the results of my examination.

Signed: _________________________________