An age-old optometry patient dilemma: Vision or medical?

Chris Wroten, OD, found opportunities to educate patients about the ins and outs of their insurance, especially those diagnosed with diabetes. Image credit: AdobeStock/LIGHTFIELDSTUDIOS

Many moons ago, a patient entered the office with “something in [his] eye” after grinding metal. He assured us he was wearing his safety glasses and goggles on top of them, but “somehow something still got in it.” And of course, this had happened 2 days earlier, but he was just now walking into the office at 4:55 PM on Friday because it was killing him, and he couldn’t get in any earlier because of his work schedule. We bit our tongue and pulled out our slit lamp to discover a dead-central 1-mm metallic corneal foreign body in the anterior stroma, with a rust ring, surrounding corneal edema, and an early subepithelial infiltrate. We explained to the patient what we would need to do to remove it in the office, including what antibiotic drops we would need to prescribe, along with dosage instructions. We would need to cycloplege the eye to ensure there was no intraocular foreign body, and that we would also insert a bandage contact lens to promote healing before seeing him in 24 to 48 hours (or sooner via the office’s on-call service should symptoms worsen). We deftly removed the foreign body with our instrument of choice, debrided the rust ring with an Alger brush without complication, painlessly inserted the bandage contact lens, and sent the antibiotic drops e-prescription to the patient’s pharmacy. Before we even had a chance to leave the examination room, the patient asked whether he would have to pay his co-pay today, whether he would have to pay again at the follow-up visit, and most importantly, whether he could go ahead and get his glasses that day because he was already here.

Another patient, this time a 67-year-old patient who’s still employed, presents with their vision insurance in hand for examination of blurred vision (OU) at distance for the past few months. Best-corrected visual acuity measures 20/50 in each eye, with grade 2+ to 3+ nuclear sclerotic cataracts and grade 1+ to 2+ cortical spoking in the visual axis OU. How should this examination be coded and billed? The reason for the visit is always driven by the patient’s chief concern, and our first diagnosis must coincide with that chief concern for insurance audit purposes. The reason for the visit in this case is to see better, the chief concern is blurred vision, and the chief cause is cataracts. After explaining the situation to the patient and ensuring their understanding, this examination should be billed to medical insurance if the patient is amenable to a cataract surgery consultation. But what if they aren’t?

Or how about the 40-year-old patient who presents for a vision examination, reporting near blur but also mentioning they’ve had moderately itchy eyes for the past few weeks? Upon examination, we diagnose presbyopia and allergic conjunctivitis. How should this be handled? The examination should be billed to the patient’s vision plan based on the reason for visit, but do we also prescribe allergic conjunctivitis medication as part of the vision examination and just schedule them to come back in a year? Or should we bring them back on a different day to deal with the allergic conjunctivitis under their medical insurance, without addressing their symptoms today? Alternatively, should the allergic conjunctivitis be treated under the vision plan but in conjunction with scheduling appropriate follow-up under the medical insurance? Or perhaps we should coordinate benefits between the vision plan and the medical insurance if that’s a possibility?

The dilemma

We’ve all experienced these scenarios (or if you’re so new to the profession that you haven’t yet, just hang in there—you will). Patients don’t understand the difference between a medical eye examination and a vision examination, and most insurance is—in my opinion—intentionally confusing to patients, making it difficult to compare plans and even harder to understand what benefits are available to them. From co-pays, deductibles, and covered services to coinsurance, noncovered services, doughnut holes, and out-of-network fees, we can barely keep it straight, even though we deal with it on a daily basis from the provider side. Nevertheless, it is important that we and our staff do our best to understand and explain insurance coverage to patients as much as we can. Even then, it never ceases to amaze me how some patients can get so upset and blame us for their large co-pay, high deductible, and/or poor coverage, despite the fact that we didn’t have anything to do with the plan that they chose or their employer chose for them. Still, the more we can help explain benefits and coverage on the front end (ie, when appointments are scheduled and/or when patients check in), the smoother it will be for everyone in the office.

It was instilled into me during my private practice externship rotation and at my first clinical position post residency that we must address medical issues first. and then vision issues, potentially during separate visits if needed. Vision care may need to be postponed until resolution of medical conditions to assure spectacle prescription accuracy and/or appropriate contact lens fit and comfort. We’ve all seen how even grade 1+ lid edema can temporarily induce –0.50 diopters or more of cylinder, so it’s incumbent to hold the patient’s refractive prescription until infection, inflammation, and/or other sequela of trauma are resolved.

Diabetic eye examinations: Vision or medical?

How about the patient with diabetes who presents their vision plan card at the front desk, saying they’re here for their diabetic eye examinations and new glasses? Early in my career, I would just perform the vision examination, dilate the patient’s eyes, thoroughly look for any retinal microaneurysms or the tiniest dot hemorrhages, and just bill the examination to the vision plan, giving away my services for free. Previously, after receiving several letters from medical insurers chastising me for not billing their beneficiaries’ diabetic eye examinations to the medical insurance, I asked my colleague Amanda Brewer-Lord, OD, what she did in her highly successful practice. As a side note, in addition to being the only entities that advocate for our patients and our profession, the beauty of participating in optometry organizations and attending their meetings (eg, the American Optometric Association, state associations, regional meetings) is the ability to network with savvy clinicians like Brewer-Lord and others who are more than willing to benchmark best practices. She shared that her practice had actively educated its patients over the years that their medical insurance covers medical eye problems, such as their diabetic eye examination, and their vision insurance covers examinations (and potentially materials) for glasses and contact lenses. Now everyone knows and expects the billing process to happen that way. The one exception to this is the limited number of vision plans that allow for coordination of benefits with the patient’s medical insurance, often resulting in the patient paying less out of pocket than they would have with just the vision plan (see more on this below).

Solutions

Similarly, I also consulted with my dentist, who does a great job making insurance coverage clear up front, informing her patients exactly what is covered and what isn’t, as well as specifically what it will cost for any noncovered services or materials.

With all of this knowledge in hand, we decided to tackle the challenge of educating our patients, especially those with diabetes, up front about the difference between a medical eye examination and a vision examination, and which provider each examination type needs to be billed to. First, we put placards at the front desk and in every examination room that assured patients that we shared their frustration with understanding their insurance benefits, but were happy to try to help. Further, the placards reminded patients that their medical insurance does not cover glasses or contact lenses; that their vision insurance does not cover medical eye problems such as diabetic eye examinations, red eyes, glaucoma, cataracts, macular degeneration, eye injuries, etc; and that insurance guidelines require us to bill medical eye examinations to their medical insurance. They were then encouraged to ask us if they had any questions. Staff also received additional training to proactively educate patients about this when they scheduled an appointment, as well as when they checked in at the front desk. After successfully implementing this many years ago, just like Dr Brewer-Lord and my dentist found in their respective practices, our patients now understand the difference between a vision examination and a medical eye examination, with rarely ever any issues arising. My only regret is not initiating this from day 1 in our practice.

In eye care, when patients present with concerns of blurred vision, as mentioned in our second scenario above, there’s a little more of a gray area. If the blur is the result of cataracts, macular edema, keratoconjunctivitis sicca, or a host of other medical conditions, it’s best to explain that to patients in the examination room. For example: “Mrs Jones, I know you’d like to get glasses today, but the main reason for your blurred vision is your cataracts. My hands are tied today as far as how much we can improve your vision with just new glasses because of how large your cataracts are now. If you’d like to see clearly again, we really need to take care of these cataracts with an 8-minute outpatient procedure, in which we remove the cataract and replace it with a clear new lens implant. We can now even incorporate your glasses prescription inside this lens implant, as close as we can get it, which usually reduces your need for glasses or contacts. Your vision and glasses benefits can then be saved until after the cataracts are removed.”

Coordination of benefits

What is coordination of benefits? It’s the one instance in which medical insurance and vision plans can work together for everyone’s benefit. Coordination of benefits is offered by some vision plans but not all (to know which vision plans in your area offer this, check with the plan itself). For those that do, the process usually requires the visit to be billed to the patient’s medical insurance first. When the explanation of benefits (EOB) is received back, indicating what the patient owes, a second claim is then filed with the vision plan for any remaining balance from the visit (some plans require the original medical EOB to be submitted with the vision plan claim). The vision plan then covers most, if not all, of the outstanding medical balance, and in some instances, the patient’s medical co-pay and vision plan co-pay both end up being fully covered, saving the patient money vs what they would’ve paid if just a vision plan claim was filed. Aside from the extra step of filing the second claim once the medical claim EOB is received, once your office protocols are in place, it’s relatively seamless and significantly benefits the patient and the practice.

In summary, investing the time to understand insurance benefits and terminology, proactively educating patients on the difference between vision examinations and medical eye examinations (and which plan each needs to be billed to), and using coordination of benefits whenever available can create a classic win-win situation for both patients and eye care providers.