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Optometry Coding & Billing Alert

Vision Benefits:
Optometrist Is in Driver's Seat When Managing Annual Vision Benefit

Ensure that the OD is aware of the patient’s benefit before recommending contacts vs. glasses.

Managing vision plans may seem like a patient’s problem, but it could become an issue for your optometry practice when you encounter unhappy patients — and then the problem will be in your lap. Fortunately, there is a solution as long as your OD works in partnership with the patient up-front.

Remember Annual Benefit

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 OD and the patient didn’t thoroughly communicate with each other. You can prevent these issues at your practice by taking a few simple steps, says Jerry Godwin, president of eye care consulting firm OMS in San Antonio, Tex.

1. Know the Patient’s Benefits

Your first step in heading off problems is to learn the patient’s coverage inside and out. “Medical insurance does have a benefit under certain plan provisions for routine vision care,” Godwin says. “These benefits can cover the exam and refraction, and provide for a materials benefit as well. All of this is in addition to their vision plan benefits.”

If the patient also has a vision plan, 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,” Godwin says. “It is a one-time per year benefit.”

2. Work With the Patient

If you expect every patient to present to your office with a thorough knowledge of her 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,” Godwin says. “The patient needs to understand what is covered and what their potential out of pocket will be
(co-pay 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 she calls to make her appointment. Then check with both payers to determine the patient’s responsibility, and let the patient know what she should expect to pay at the time of her visit.

3. 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 she 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 lies with the doctor not properly managing the patient’s condition and expectations,” Godwin says. “The doctor must educate the patient and advise them on a treatment plan to care for their condition. 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 him or her to ensure that the patient is aware of the best clinical treatment option at the time of prescription.