As an optometrist, we're dedicated to providing the best possible care for our patients, and understanding their medical insurance, especially regarding vision coverage, is critical for providing that care.
Uncovering Hidden Vision Plans
We know that medical insurance plans cover medically necessary eye care, but did you know that some medical insurances also cover routine vision exams? These "hidden" vision plans, often included within broader medical insurance policies, can significantly impact coverage. Providers who effectively navigate these plans can ensure their patients receive optimal care while also maximizing their optometry practice's revenue through strategic insurance billing.
Maximizing Revenue
My practice is in-network with Spectera, as are thousands of other optometry practices across the US. However, despite a large percentage of our patients having Spectera, we rarely ever bill them. Why? Because Spectera is the vision carrier for United Healthcare, and many United Healthcare plans include their own vision coverage. This means we can choose to bill either United Healthcare or Spectera (but not both) for a patient's routine visit. Currently, United Healthcare pays almost three times as much as Spectera, and both plans have zero copay for the patient. That makes it a pretty easy decision.
Navigating Insurance Coverage
Finding out which medical plans cover routine vision can be tricky. While some eligibility portals offer information, they're often vague on specific vision benefits. I prefer calling the insurance company's provider line for clarity. Specify that you're asking about routine vision benefits. They might ask for a CPT code (use 92015) and a diagnosis code (use H52.03). Ask the representative about the patient's exam copay, coverage limits, contact lens fitting, and eyewear coverage.
Billing Strategies
If I'm unsure, I usually bill the routine codes to the medical plan first. A paid claim indicates coverage for routine care, while a denial prompts me to submit to the vision plan. Maintaining a list of medical plans with routine vision coverage can streamline billing decisions and save time
Important Billing Tip
When billing medical insurance for a routine exam, ensure the claim only includes refractive ICD-10 codes. Any medical diagnosis codes will trigger the patient's regular specialist copay and deductible. However, if the patient presents with a medical complaint, remember to submit the exam to their medical plan, regardless of any routine benefits.
I hope this article has provided valuable insights into uncovering patient benefits that you may have been missing. Taking just a few extra minutes to explore insurance coverage could lead to a significant increase in your optometry practice's bottom line. If you have any questions, please don't hesitate to reach out to me. Your success is important, and I'm here to help in any way I can.
The recommendations in this blog post are based off of my own practice experience and not a guarantee of any income you will receive.
