Medical vs. Vision Insurance

 

 

One of the most challenging billing issues in an eye care office is whether we should be billing the medical or vision plan. With all the new changes to insurance coverage, we often have patients with both medical and vision insurance. These two types of coverages are very different, and while these differences can be confusing, it is very important that our patients understand both their benefits as swell as the limitations of their insurances. Please review the information below that was written to help clear up these differences.

 

• VISION insurance is designed to cover, either in part or in whole, the process of determining a prescription for glasses, along with a routine evaluation of the health of the eyes. Some insurance plans will also offer coverage toward the purchase of contact lenses and/or glasses.

• In contrast, MEDICAL insurance in designed to provide coverage for the diagnosis, treatment, and management of ocular diseases, but typically does not cover routine examinations including glasses and/or contact lens examinations.

 

If, during the course of your yearly eye exam, your eye doctor discovers a medical condition, the bill for coverage cannot be submitted to the VISION insurance and must be submitted to the MEDICAL insurance. Failure to do so may be considered insurance fraud.  Similarly, if it was a medical condition that motivated the visit to the office, the bill must be submitted to your medical insurance and not your vision insurance.

 

When a diagnosis such as cataracts, glaucoma, allergies, conjunctivitis (pink eye), dry eye, high blood pressure, diabetes, or other issues are documented, we must file the claim with your medical insurance, and the co-pays and deductibles for that insurance will apply. It is very important to realize that VISION insurance does not cover these types of conditions. As such, it may be sometimes necessary to schedule a second visit to comply with insurance regulations and the required testing therein.

 

Unfortunately, there is no way to know prior to your examination what medical conditions may be affecting your eyes, and therefore, we do not know to which insurance your claim will be filed. We make every effort to be in 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 with your insurance yourself for reimbursement directly from them.

 

Lastly, if we do file the exam with your medical insurance, you can still use your Vision Plan benefits towards the purchase of glasses or contact lenses based on your plans allowances. At times it can seem like a complicated process, but these are the rules set by your insurance company. We would be happy to answer any questions that you may have about your insurance coverage.