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Financial Policy

Medical Care vs Wellness Care

Many patients have both discounted vision plan coverage (VSP, Eyemed) and medical insurance (Medicare, Aetna, BCBS etc). There is a significant difference between what the vision plans and medical insurance cover when it comes to eye care services. There is no such thing as an all-encompassing "eye" insurance.

You must provide our office with all of your vision plan and medical insurance information before your exam Any pre authorizations for visits are the responsibility of the patient to obtain in advance of their appointment. All copays and applicable deductibles are the financial responsibility of the patient or responsible party.

Some Definitions

Vision Plans: Pay for a refraction (to determine an eyeglass prescription) and basic eye health screening examination. They do not cover the examination, evaluation and treatment of medical eye problems such as dry eye, diabetes, high blood pressure, eye infections or injuries.

Medical Insurance: Pays for the examination and treatment of medical eye problems such as dry eye, cataracts, eye allergies and other medical conditions which may affect the health of the eyes. These plans do not cover refractions.

Copays: Are fees we are required to collect at the time of your examination by either your vision plan or medical insurer. These vary based upon your coverage.

Deductibles: This is the annual amount you must pay before your medical insurance pays any medical expenses. This amount is determined by the type of plan and contract you have signed with your medical insurer. Your insurer will notify us if a deductible has been applied to your claim and the amount you must pay our office. We will bill you for the deductible once notified of the amount by your insurer.

Out of Network: If we are not on the provider panel for a vision or insurance plan, we are considered to be an out of network provider. We will be happy to care for you but all fees must be paid by you directly and you will have to apply with your plan to see if they will reimburse you for any of those fees.

Refraction: Is the test used to determine your eyeglass prescription. Medicare and other medical insurers do not cover the refraction fee. You will be responsible for paying that fee.

Refraction (testing your eyes for glasses) is a separate procedure from the medical eye exam and many insurance plans do not cover this. Midlothian Eye Care typically performs this procedure on every patient unless specifically requested not to. You will be charged for this fee if your insurance does not pay for it. We can only guarantee the accuracy of refraction for 90 days. After 90 days, a new refraction fee will incur for checking a prescription.

Any balances remaining unpaid for more than 90 days will accrue interest at the rate of 1.5% compounded per month. You are responsible for all additional fees incurred in an effort to collect on your account. Balances over 180 days old will be turned over to a collection agency. You may be taken to court to collect any fees. Unpaid fees can be reported to credit bureaus and the IRS. If you do not give 24 hours’ notice before cancelling or rescheduling an appointment, you will be charged a minimum of $60.

I have read and understood the information above. I have been provided the opportunity to ask any questions I had, and all questions have been answered to my satisfaction. I agree to abide by these policies.  

Some Questions and Answers

Will my vision plan pay for my annual diabetic eye exam?

No. Your exam is considered medical in nature and is not covered by vision plans.

How do I know which of my plans will cover my eye exam and other services?

We often do not know until our doctors evaluate your vision complaints and their causes. If you have blurred vision and it is caused solely by a change in your eyeglass prescription, then your vision plan coverage is used. If it is found that the cause of your blurred vision is due to cataracts, dry eye or other medical eye problems, then your medical insurance will be billed.

Can I use both plans for the same visit?

This is a possibility. If you have a medical eye problem which is stable and we are able to find a valid eyeglass/contact lens prescription, the exam will be billed to your medical plan, and you may be able to use forms we provide for you to do coordination of benefits for the vision plan to reimburse you for a portion of your refraction fee.

If I have a high annual deductible for my medical plan, can you waive collection of those fees?

No. Under Federal law, that would be considered insurance fraud. We will not do that.

What is a refraction?
The refraction is a separate procedure/code from an ocular examination. This is the procedure when we ascertain your prescription for glasses and ask "Which is better - 1 or 2?".
Why is the refraction not covered by my medical insurance?
Many Medical insurance companies will not cover the refraction for routine purposes. Refractions are considered part of preventative care, not medical care.
My eye exam went medical, why can’t it be billed to my vision insurance?

Vision insurance is a Wellness vision benefit plan, they will not process claims with medical reasons.  We do however try to work with your vision insurance to maximize your benefit in conjunction with your medical insurance. But please be aware, not all vision plans allow for Coordination of benefits.

  1. What happens if my policy does not allow for coordination of benefits? If your vision insurance does not allow us to bill in conjunction with your medical insurance, you have 3 options.
    1. Option 1: Perform a medical exam and vision exam on the same day.

      - For those using VSP vision insurance, this is easy and is called "Coordinated Billing" or COB. VSP allows for COB and they make it easy and simple.

      - For those using EyeMed vision insurance which does NOT allow for COB, you will have to pay fore the refraction up front and then submit your own paperwork to try and get reimbursement. This is due to their policy, not our's.

    2. Option 2: Perform medical exam on one day and vision exam on another day. This of course requires 2 copays and days off from work - not ideal, but it is an option that some take.

    3. Option 3: Be referred to a specialist for the medical exam and come to us only for the vision exam AFTER the medical exam is performed. This requires extensive and ongoing communications between our office and the specialist office. This of course requires 2 copays and days off from work - not ideal, but it is an option that some take.
What is a deductible?

The Deductible is your out-of-pocket cost prior to your plan paying for medical care. You must first pay off your Deductible before your insurance will start to pay for anything. Deductibles reset once a year. 

How much is my deductible?

We do not know - please contact your insurance company for your  specific deductible amount and timeframe. 

Why are the advanced screening tests not billable to my insurance?

Advanced Screenings are not billable to any insurance and are considered preventive care. If something of concern is found during a screening, we can perform a separate high-quality test which may be billable to your insurance.

Can we bill non-covered services to your insurance?

The Advanced Screening tests do not have any CPT codes attached to them; therefore, they are not billable to any insurance. These are considered out of pocket expenses that are optional yet recommended.

Will I receive any additional bills after my visit?

Your insurance has final say in coinsurance and covered benefits. Your insurance company may state if you owe any addition amount due to Coinsurance, Copay, or deductible. We cannot be certain of any of these numbers until we receive the Explanation of Benefits (EOB).

Will my secondary insurance pick up my Medicare deducible?
No, most secondaries will not pick up your Medicare deducible. Please consult with your insurance for more information.
Does Medicare cover an eye exam?

YES! Medicare will cover the medical, ocular examination; however, Medicare will NOT cover the refraction. Therefore, we do not bill Medicare for this procedure and instead bill the patient's guarantor.

Will you code my medical exam with a vision code so that I can use my vision insurance?

This is a type of insurance fraud in which our office does not participate. Our office bills appropriately according to the chief complaint and final primary diagnosis which is determined by the examination findings. 

 Therefore, final codes cannot be assessed until after the examination is complete unless we know of a medical condition or medical chief complaint ahead of time.

Vision Reimbursement Forms

Our office will submit vision claims to VSP and EyeMed as a courtesy; however, if you have another vision insruance, you are welcome to be seen by one of our doctors. If you wish to submit your claim for reimbursement to one of these vision insurances, the claim form links are provided below.

Davis reimbursement form
Spectera reimbursement form
National Vision reimbursement form
Ameritas reimbursement form
EyeMed reimbursement form (leave 'reason' blank per EM instrucitons)

Learn More: How do we determine medical vs vision?

How do we determine medical vs vision? 'We' do not - the examination does. The final codes related to any examination are derived from the chief complaint as well as the examination findings. Therefore, final codes cannot be assessed until after the examination is complete unless we know of a medical condition or medical chief complaint ahead of time.

Example medical exam #1: Known diabetic: these patients require a medical examination to ascertain the existence of diabetic retinopathy and at what level. These patients require more time, more coding, more paperwork, and also are a higher-level liability to the practice. Diabetes is the #1 cause of permanent vision loss in the US; therefore, we do not cut corners and spend the appropriate amount of time and resources on these patients.

Example medical exam #2: No known medical conditions; however, a significant medical issue is found during the exam which requires immediate attention. Incidental medical issues found which are unrelated to the chief complaint such as iris nevus, arcus senilis, visually-insignificant cataracts, pinguecula, etc do not need immediate attention, treatment, or education and therefore do not fall under this category.

Example 1: During a routine vision exam, we find a giant retinal detachment or significant retinal bleeding that must be documented, photographed, and referred to a retinal surgeon. This new code "retinal detachment" or "retinal hemorrhage" will override any vision codes as the primary diagnosis. Some vision insurances will not pay for the exam at this point unfortunately such as EyeMed. VSP however does allow for "Coordinated Billing" or COB.

Example 2: During the initial part of the exam, a patient complains of itchy eyes, dry eyes, flashing lights, or some other medically-related issue that they would like the doctor to evaluate and treat. At this point, the examination becomes medical due to the chief complaint and hence, the primary diagnosis. 

Example medical exam #3: The patient comes in for a 'routine' vision exam, but in the chair complains of multiple medical issues that they would liek the doctor to evaluate and treat.

Example 1: "I'm here for my eye exam, but I've been having terrible headaches and my eyes have been very dry and red in the morning."

Example 2: "I'm here for my eye exam, but I've been seeing a lof of floating spots in my left eye for about 3 weeks now."

If you know you have a medical condition that we must evaluate and treat you have 3 options:

Option 1: Perform a medical exam and vision exam on the same day.

For those using VSP vision insurance, this is easy and is called "Coordinated Billing" or COB. VSP allows for COB and they make it easy and simple.

For those using EyeMed vision insurance which does NOT allow for COB in most cases, you will have to pay for the refraction up front and then submit your own paperwork to try and get reimbursement. This is due to their policy, not our's.

Option 2: Perform medical exam on one day and vision exam on another day. This of course requires 2 copays and days off from work - not ideal, but it is an option that some choose.

Option 3: Be referred to a specialist for the medical exam and come to us only for the vision exam AFTER the medical exam is performed. This requires extensive and ongoing communications between our office and the specialist office. This of course requires 2 copays and days off from work - not ideal, but it is an option that some choose.

Why can't the doctor just code my exam as vision to save me money? This is a type of insurance fraud in which our office does not participate. We bill appropriately according to the chief complaint, examination findings, and primary diagnosis.

Vision insurance is NOT "eye" insurance. We accept both vision insurance for routine, healthy checks but also medical insurance for those with either 1) known medical issues or 2) if there is a significant medical issue found during the examination that takes precedent over your chief complaint.


Medical or Vision Flow Chart

Medical or Vision Insurance?

Use the following chart to see how your exam will be billed.

Important factors to consider

Diabetes

If you are being treated for high blood sugar (the leading cause of permanent vision loss in the US), your exam will be sent through your medical insurance, not vision insurance. If you have EyeMed, please read below** or call 804-595-2020, ext 4 and ask for details BEFORE making appointment.

Understanding Deductibles

The patient guarantor is responsible for all deductibles. If your exam is coded medically and is billed to your medical insurance, you will be responsible for the amount that is applied to your deductible. Exams are coded appropriately according to the chief complaint and examination findings. 

Contact Lens Wearers

The fitting and/or evaluation/update of contact lenses is separate from the eye exam & there is a separate charge for this service. It may not be covered by your insurance.

**Patients with EyeMed Vision Insurance

In order to use EyeMed vision insurance, EyeMed now requires exams to be vision-related only (meaning your primary diagnosis is nearsightedness, farsightedness, or presbyopia - 'over 45 eyes').

This means EyeMed will NOT pay for your exam if you are being treated for high blood sugar, complain about itchy, red, dry eyes, have any medical complaints that you would like your doctor to evaluate and treat during your examination, or if a signitifcant medical issue is found during the exam which must be documnted, evaluated, and treated on that day.

  • What are my options if I have a known medical condition or medical complaint such as dry eyes, itchy eyes, watery eyes, or a bump I'd like to have evaluated?

    If you 1) have any medical complaints that need to be addressed during your exam 2) significant medical issues arise during your vision exam or 3) you have known medical issues that must be addressed (including but not limited to: high blood sugar (diabetes or pre-diabetes), cataracts, itchy and/or red eyes, dry eyes, glaucoma, retinal neoplasm, etc), you have 3 options:

    Option 1: Perform a medical exam and vision exam on the same day.

    For those using VSP vision insurance, this is easy and is called "Coordinated Billing" or COB. VSP allows for COB and they make it easy and simple.

    For those using EyeMed vision insurance which does NOT allow for COB, you will have to pay fore the refraction up front and then submit your own paperwork to try and get reimbursement. This is due to their policy, not our's.

    Option 2: Perform medical exam on one day and vision exam on another day. This of course requires 2 copays and days off from work - not ideal, but it is an option that some take.

    Option 3: Be referred to a specialist for the medical exam and come to us only for the vision exam AFTER the medical exam is performed. This requires extensive and ongoing communications between our office and the specialist office. This of course requires 2 copays and days off from work - not ideal, but it is an option that some take.

Other vision insurances such as VSP make it easy for patients with medical issues to have both the medical exam and refraction done on the same day. We recommend you consider this when choosing a new vision insurance.

Confused?

If any of this is confusing, please call 804-595-2020, ext 4 and ask for details before requesting an appointment. Thank You!