Ophthalmology and Optometry Coding Alert

Contacts vs. glasses? The vision plan may not cover both.

A vision plan is different from a health insurance policy, but many patients don’t realize that. While some vision plans may be fairly straightforward, others have nuances you’ll have to know so you can ensure that the patients get maximum benefit when you work to correct their vision.

Picture this: A vision plan covers either contacts or glasses every year, and your 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 this scenario sounds familiar, chances are that the practice and the patient didn’t thoroughly communicate with each other. You can prevent these issues at your office by taking a few simple steps.

Know the Patient’s Benefits

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 also 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, says Gina Vanderwall, OCS, CMBS, CPC, CPPM, CPC-I, MFG coding educator with the University of Rochester Medical Center in Rochester, New York.

Work With the Patient

If you expect every patient to present to your office with a thorough knowledge of their plan provisions, it’s time to reevaluate your assumptions.

It is up to the practice to properly educate the patient on their benefits — both medical insurance and vision plan coverage. The patient needs to understand what is covered and what their potential out of pocket will be (copay and deductible). All of 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.

Ensure That the OD Is on Board

If you follow steps one and two above, 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 like in our example above, 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 optometrist 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 optometrist 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 optometrist 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.