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Preventive Care, Routine Vision Care and Medical Care

Vision Insurance vs. Medical Insurance (Preventive Care or Medical Care)

One of the most challenging issues in an ophthalmology office is whether we should be billing our patient’s Vision Insurance or Medical Insurance for their office visit. To complicate things further, the Affordable Care Act (ACA) introduced the inclusion of Preventive Vision Care as a benefit to many of the ACA compliant medical plans.

While at your office visit if there is no medical discovery, your visit is considered a Routine Visit and your Vision Insurance or Medical Insurance (if you have a Preventive Care Benefit) will be billed for the visit.

Vision Insurance plans provide coverage for routine exams, glasses, and contact lenses, or in some cases proivide some type of discount on the doctor’s fees. If you have trouble with your vision (nearsighted, farsighted, astigmatism, etc.), your visit is considered a vision problem and will be billed to your Vision Insurance plan.

Medical Insurance with a Preventive Care Benefit will provide coverage for the routine examination only. Eyeglasses and/or contact lenses will be an additional charge.

If we discover that you have a medical problem (infection, corneal disorders, diabetes, a lazy eye, cataracts, glaucoma suspect, dry eye, double vision, etc.), your visit is considered a medical problem and is will be billed to your Medical Insurance as a Medical Care Visit.

Medical Insurance plans provide coverage for medical conditions and you are subject to the Medical Insurance plans co-pays and deductibles associated with your Medical Insurance plan.

Routine vs. Medical Eye Exams

Office visits to an eye care professional are usually categorized as either "routine" or "medical". This terminology has nothing to do with the steps it takes to perform a comprehensive eye exam, or the type of doctor who performs the exam. A comprehensive "routine" vision exam often contains the same elements as a comprehensive "medical" eye exam, and seeing an ophthalmologist (MD) doesn't make the exam medical in nature.

The type of eye exam you have is determined by the reason for your visit or your chief complaint, as well as your diagnosis. Routine vision exams usually produce final diagnoses such as nearsightedness or astigmatism,
while medical eye exams produce diagnoses such as conjunctivitis, cataracts
or glaucoma, etc.

Most insurance companies focus on the reason for your visit to determine
its visit type and who is responsible to pay for the visit.

Real-Life Examples:

Example 1

: Let's say your employer provides both types of insurance --
medical insurance as well as a separate vision plan, such as EyeMed.

You decide that it's time for your annual eye exam because your glasses are
falling apart. You see your Optometrist (OD) for a routine eye exam and to
purchase new glasses. Your doctor’s office authorizes your benefits so you
proceed with the examination. At the end of the exam, your doctor informs
you that in addition to a minor prescription change, he/she found signs of
glaucoma. You are instructed to return in one week for additional tests.

Remember that your original reason for the visit had been to have an eye
exam and to purchase new glasses. Even though your doctor found signs of
glaucoma at the end of the examination, this visit would be covered under
your Vision Insurance or Preventive Care under your Medical plan" because
the main reason for the visit was to get your vision checked for new
glasses. But, because at the end of that exam you are considered a
potential glaucoma patient, your medical insurance will be billed for the
additional tests and office visits related to the medical diagnosis of
"glaucoma suspect." *Please note that any co-pays and/or deductibles
associated to your medical plan will apply to these future “Return to
Office” visits.*

Example 2

: You decide that it's time for your routine eye exam because
your vision benefit has renewed and will allow you to have a routine exam
and new glasses, but you also have an ongoing medical condition that the
Ophthalmologist (MD) or a Therapeutic Optometrist (OD) treats you for. In
order for your vision benefit to cover the exam, you must specify that your
reason for coming in is to have a routine exam and new glasses, and that
you are under an Ophthalmologists care for your medical condition.

The above “Real Life” example would apply to Medical Plan that has a Vision
Preventive Care Benefit associate to it.

Refraction Fees

What happens if you have concerns about your eye health but you also need
new glasses? Can you have your vision checked even though you have a
medical eye problem? The answer, of course, is yes. However, your eye
doctor may charge you a refraction fee. Medical insurance companies usually
separate the components of an eye exam, one being the comprehensive exam
and the other being the refraction. Typically, vision insurance policies
cover both the eye exam and the refraction, while medical policies cover
the exam only.

The Lavenburg Medical Group participates with hundreds of insurance plans
offering Preventive Care and medical benefits. With so many variations of
plans for our patients to choose it is very difficult for us to be experts
on all plans. Therefore, we strongly encourage our patients to be familiar
with their individual insurance plan, its benefits, co-pays and
deductibles.

Our billers will determine the appropriate plan (medical or vision) to file
your claim, based on the results of your exam. Your insurance company will
determine if the office visit is considered a Routine Office Visit or
Medical Office Visit.

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