MANAGED CARE UPDATE

Is That 'Vision' or 'Medical'?

by Randolph Brooks, O.D. 

You've just performed a comprehensive eye exam, complete with extensive pre-testing and a dilated fundus exam, and you bill the patient's medical managed-care plan. You list myopia as the diagnosis, but the plan denies your claim. You treat another patient's glaucoma and bill her vision plan. This plan also shoots down your claim.

Each plan tells you it doesn't cover the diagnosis you billed. You're so frustrated you're ready to pull your hair out. And, you're not sure which type of plan, if any, would cover your services.

This problem didn't exist 23 years ago when I went into practice. Optometry was mostly a vision-care profession. Although we delivered eye-health care, we were mostly concerned with diagnosing the patient's visual condition and referring him or her out for medical care.

Since then, optometry has emerged as a primary eye care profession. Various managed-care and vision-care plans have emerged as well. You'll need to deal with them in different ways to get paid. Here are four questions you might have on how to do so.

1. Which plan do I bill? Check with each plan about which services and diagnoses it covers. Some general guidelines:

  • A vision plan may only reimburse you for a refractive diagnosis such as myopia (367.1), hyperopia (367.0) or presbyopia (367.4). This plan might reject a claim that lists a medical eye problem as the primary diagnosis.
  • A medical plan that does not cover "routine" vision care will reject a claim that lists a refractive problem as the diagnosis, but will cover an office visit for a medical eye problem such as glaucoma or diabetic retinopathy.
  • If the managed-care organization carved out all eye care services to a vision plan, bill the vision plan.

2. What if I see the patient under a vision plan and discover a medical eye problem? Bill the vision plan and list the refractive problem as your primary diagnosis. List the medical problem as a secondary diagnosis. When you provide follow-up care, bill the patient's medical plan and list the patient's medical eye problem as your primary diagnosis.

3. What if the patient has separate medical and vision coverage, but I only belong to one of those plans? If you're on the patient's medical plan and you discover a problem, tell the patient the plan will probably cover his or her care. Patients often assume that a plan that won't cover a routine exam for eyeglasses won't cover treatment of a corneal abrasion or glaucoma. They're wrong.

If you're on the patient's vision plan and discover a medical problem, let the patient know that his or her medical insurance will cover the care, but only if a doctor on that plan's panel provides it. If the patient isn't willing to pay you out of pocket, you'll need to make arrangements for him or her to receive care elsewhere.

4. How do I handle recall? If the patient's plan only covers one eye exam every two years, explain to the patient why he or she should return every year, even that means paying out of pocket.

If the patient requires more frequent follow-up for a medical condition, his or her medical managed-care plan should cover the visits. Remind the patient to get the proper referral from his or her primary care physician. Send report letters to the patient's PCP, explaining why the patient must see you more often. The physician will then have this information on hand when the patient asks for a referral.

When it comes to plans, "vision" and "medical" mean two different things. Learn those differences and you could save yourself a lot of aggravation.

 

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