Ophthalmology and Optometry Coding Alert

Question: We had a patient present her insurance card and when she left, the office manager told me I collected a vision plan card, not an insurance card. What’s the difference?

Codify Subscriber

Answer: A vision plan is different from a health insurance policy, but many patients — and some eye care practice staff members — don’t realize that. While some vision plans may be fairly straightforward, others have nuances you’ll have to know to help ensure the patients get maximum benefit when you work to correct their vision.

A vision plan covers an eye health exam (aka, routine eye exam) and either contacts or glasses every year or every other year. But in some situations, your patient may not realize they’ve hit the limit. For instance, suppose a patient asks for contact lenses — but after taking them home, she finds that her eyes are too dry to use them, and now she’s complaining to your front office staff that she has to go out of pocket to buy glasses because she already used her benefit on the contacts. If you’re at the front desk at your practice, you are instrumental in identifying the difference between these programs.

Your first step in heading off problems is to learn the patient’s coverage inside and out. Some insurance plans do have a benefit for routine vision care. These benefits can cover the exam and refraction and provide for a materials benefit as well.

If the patient has a vision plan in addition to health insurance, find out what the coverage details are — but remember this distinction: Vision plans are not insurance. They are a discounted fee for service plan that provides for an exam/ refraction and materials or contact lens benefit. Patients can usually use these benefits once a year, although some plans cover new glasses or contacts once every two years. However, this isn’t always the case. Some vision coverage actually works as an insurance plan. They pay the provider directly and the patient has little or no copayment. That’s why it’s essential to understand the feature of the patient’s plan before they present to your office.

While it should be the patients’ responsibility to understand their insurance, not all do. It is then up to the practice to properly educate patients on their benefits — both medical insurance and vision plan coverage. Patients need to understand what is covered and what is non-covered, as well as their potential out-of-pocket costs (copay and deductible). Ideally, this should be done prior to the patient’s visit.

To accomplish this, gather the patient’s health insurance and vision plan information when they call to make an appointment. Then check with both payers to determine the patient’s responsibility, and let the patient know what they should expect to pay at the time of the visit.

If you follow these steps, your patient should be well aware of the fact that they can get glasses or contacts every year, but not both. However, if you do encounter a situation where the patient is unhappy with contacts and complains about having to go out of pocket for glasses, it’s possible that the issue stems from your eye care provider and not your front office staff.

The problem sometimes lies with the doctor not properly managing the patient’s expectations. The doctor must educate the patient and advise them on a treatment plan to care for their conditions. Glasses are a source of treatment for the patient’s medical condition if they are not capable of wearing contact lenses.

Since the provider is the only person who can clinically determine whether the patient’s eyes are suitable for contact lenses, it’s up to them to ensure that the patient is aware of the best clinical treatment option at the time of prescription.

If you see situations like this happen frequently, talk to the physician and let them know the basics of most patients’ vision plans so they can speak with the patient about their options in a way that’s both clinically and financially viable.