Vision Plans vs. Medical Insurance: When Should You Bill?

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Many patients have both medical and vision insurance. It can be confusing and challenging to decide which to bill, especially when patients want to be part of the decision and are concerned with what they will have to pay. 

Sometimes, patients even ask you to charge their vision plan instead of their medical insurance. 

While the best billing practice is to select which plan (vision or medical) to bill based on the patient’s chief complaint and diagnosis, sometimes it’s more complicated. Verifying both vision and medical plans before the office visit is critical. 

This blog discusses best practices for billing vision plans and medical insurance. In addition, we’ll review three case examples where patients have a vision plan and medical insurance.

Vision Plans Vs. Medical Insurance Billing Tips

  • Never bill both vision plans and medical insurance simultaneously for the same service.

  • Vision plan insurance is for “routine” eye examinations (eye refractions); most plans permit vision insurance to be used one time per calendar year. The exam and refraction are combined (do not separate into examination and refraction).

  • Some medical insurance plans cover one routine examination per calendar year. Often medical insurance plans cover the diagnosis codes for myopia, hyperopia (sometimes referred to as hypermetropia), astigmatism, and presbyopia. Medical insurance usually pays at a higher rate than vision plans. If the doctor sees the patient for a routine eye examination and the medical insurance covers the exam, you should bill medical instead of vision.

  • Verify both medical and vision plans before the office visit. Scan or copy both sides of the cards. Verify if you need a prior authorization number before you see the patient. Double-check that the prior authorization number is on the insurance claim.

  • Inform the patient what deductibles and co-pays you will collect before you see the patient.

  • Document the patient’s history, exam, assessment, and plan. When you document the chief complaint, provide a concise description of the problem or laboratory test—this will help you if you are ever audited. A missing chief complaint can result in a claim denial based on incorrect levels of care.

    • Follow these 12 optometry billing tips to help improve patient collections and generate a healthy bottom line for your eye care practice.

  • If you suspect that Medicare (or commercial non-Medicare insurance) may not cover a procedure or service, obtain an Advance Beneficiary Notice of Noncoverage (ABN) before providing the specified procedure or service to the patient.

Patient Case Examples: Vision Plans Vs. Medical Insurance

The following examples are established patients with vision plans and medical insurance who have seen the doctor for a routine eye exam.

Patient Case #1

During the dilated eye exam, the doctor detects a choroidal nevus (sometimes called an eye freckle). Because melanoma can resemble a nevus, the doctor may perform extended ophthalmology services on the same day.

The exam can now be billed to the medical insurance since the doctor used medical diagnosis codes. Always list the medical diagnosis codes as primary diagnosis codes to avoid rebilling.

Patient Case #2

The patient is being seen for their annual eye exam because they need new glasses. During the exam, the doctor determines the patient has glaucoma (a medical condition).

Since the “exam reason” is for new glasses, you should bill the exam to the vision plan. However, additional exams (during a separate visit on a different day) pertaining to treating glaucoma are billed to the medical insurance.

Patient Case #3

While you should never bill medical insurance and vision plans simultaneously for the same service, let’s examine a typical scenario our Fast Pay Health billing team often encounters.

Suppose you bill the medical insurance, which covers routine eye examinations, with CPT® codes 92014 and 92015 with a diagnosis of myopia, hypermetropia, and astigmatism, but the insurance only pays you for CPT® 92014. In our experience with many practices, once the practice receives payment for CPT® 92014, we coordinate with the vision plan to get paid for CPT® 92015.

Error-Free Optometric Billing Means You Get Paid Faster

Submitting clean vision plan and medical insurance claims is essential to getting paid faster. The Fast Pay Health team are experts in ophthalmology and optometry billing. We help ensure claims are error-free and submit them promptly, reducing rejections and speeding up payment. Get started today with a free practice analysis.

CPT® is a registered trademark of the American Medical Association®.