Wiki Question about Coordination of Benefits between Medical and Vision Insurances

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ashumack

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Hello,

I am not extremely familiar with filing vision claims and I have tried to research this topic. Most instances it seems that it depends on why the patient is here as to who to bill to as primary, but my question comes in when the patient has a medical insurance and has either a copay, deductible, or coinsurance amount and if vision acts as a secondary to cover these amounts or if the patient is responsible.

The way it has "always been done" here at the clinic I work for is that when the patient's medical insurance comes back, they file the remainder to any applicable vision policy. I understand that a refraction would be covered in this instance if not covered by the primary, but they have historically changed the diagnoses on the claim for to all vision codes and taken off all the medical. To me this seems incorrect. If the vision insurance acts as a true secondary on medical, then we should be filing the claim exactly the way we did to the medical insurance and not change any diagnosis codes. If their exam was billed as medical because their reason for visit was medical, then that should follow the claim form to the vision insurance company.

My co-worker who has been filing these claims stated that she called the vision company and explained my concerns and the vision company apparently told her it didn't matter what diagnosis was on the claim. As long as they had the primary EOB, they would process the claim. Now I don't trust what she is saying which is obviously why I am posting my question here.

Thanks in advance for helping me with this.

Amber
 
What the practice is doing could be considered either abuse or fraud IMHO. To my knowledge, the only vision plan we ever participated with that did COB was VSP. We would send them a copy of the EOB from the medical insurer, with the medical diagnosis codes, and VSP would pay the refraction fee, if there was one, up to their allowable amount and they would then pay some or all of the copay for the medical plan as long as it was less than the exam benefit for the patient.

A question for you. Let's say the balance due is $40 but the vision plan pays $75 to your office. What happens to the over payment of $35? Is it refunded to the patient or kept by the practice?

At any rate, changing the diagnosis codes on the claim sent to the vision plan, just so they pay is unethical at best and fraud at worst. If the office is ever audited by the vision plan, and they are doing that a lot now, someone is going to owe them a great deal of money.

Personally, I think what your fellow employee has told you about her call to the vision plan is BS.

Tom Cheezum, O.D., CPC, COPC
 
Vision Secondary

I can only tell you what VSP here does. We submit our secondary claims online through their website. The have told us to tie the vision code to both exam and refraction but when I input I list all diagnosis, and leave the medical as the primary. So for example Exam billed as A)E11.319 B) H52.13 and C)H52.223 with Exam tied to A) as primary diagnosis. When I submit it to VSP I would list them in the same order but tie exam and refraction to B) as primary diagnosis, then submit how much insurance paid, and adjusted. You can also go online to their website and it list different scenarios for COB claims. I hope this helps.
 
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