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Medical vs. Vision Care Claim Processing

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Young woman sitting on chair with optician standing while doing eye test in ophthalmology clinic.

Handling claims regarding optometry and ophthalmology can entail a string of tiny details, including differences between billing to a vision plan versus what you should bill through a patient’s medical insurance. Differentiating between the two can often be a little confusing at first, and that’s okay. To make things easy, let’s review what the differences between both types of claims are, why they’re important, and how you can make handling them a seamless process.  

Vision Plans vs Medical Insurance 

The average medical health insurance policy covers unexpected emergencies, meaning that routine eye exams, contact lenses and glasses are not considered or covered by that policy. However, should there be an accident that requires an emergency or unexpected procedure and exam, medical insurance will typically cover a portion or all of the cost depending on the policy holder’s agreement with their insurance company.  

Vision plans are typically reserved to help cover things like: 

  • Annual eye exams  
  • Eyeglass frames and lenses 
  • Prescription contact lenses 

Vision insurance plans will not usually help cover any exam that needs medical attention. Considerations for medical insurance may include allergies or dry eyes, infections, vision loss, or complications with eyesight caused by underlying health problems such as diabetes. A great rule of thumb to determine whether a plan falls under medical or vision care is by determining whether treatment is a requirement. If a patient is being treated for their eyesight rather than purchasing eyewear to simply assist in correcting their vision, then it will fall under the medical claim category.  

One thing to keep in mind when filing a claim is that sometimes during routine eye exams there could possibly be elements of the exam performed that are considered as ‘medical’ necessities. This is important to communicate with anyone staffed that’s handling claims, as it could change the way a claim is submitted and processed.

Does It Really Matter Which Policy I Bill To? 

Filing a claim with the correct care policy is essential in ensuring that you’re able to collect the money for your services. If you file a claim with the incorrect policy, you may find that you receive a rejection from that patient’s insurance company and have to re-submit the claim towards the correct policy. Additionally, some services may require that you file with both medical and vision care to receive the full fee you’re owed.  

It’s important that prior to a patient meeting with the doctor, you let them know how you’re planning to file with their insurance. This assists in letting them know if there’s a potential co-pay or that they may receive a final bill following the claim’s payout. Some medical or vision care agencies may only cover part of the fees. In situations like this, you may find that filing with vision care first will help cover part of the bill, and following up with medical care after might cover the rest of the owed fees or part of it, before mailing your patient an adjusted bill.  

By submitting claims to the proper plan, you can offer your patients a transparent and affordable plan of action. Not only does this help you prevent delays in receiving payments, but it’s great for reassuring patients that your clinic cares about their wellbeing and their vision. This is great for building patient-to-practice relationships and gaining rapport with anyone scheduling an appointment through your clinic. 

A doctor assessing a patient’s treated eye injury. 
When it comes to insurance claims, some emergent injuries or serious conditions may be billed to medical rather than vision insurance payers. Doctor examining wheelchair patient after eye surgery.

Following Up on Payments Due 

Sometimes submitting a claim to a third-party policy isn’t simple. Each agency has its own specific set of processes and standard regulations they must follow before fully processing a patient’s claim. This can include checking if the policy is up to date, if there’s a potential deductible that hasn’t been met, and verifying if that subject’s policy covers all of a claim or part of it. Some vision insurance plans, considered as discounted plans, work with doctors to offer a discounted rate of the total fee rather than co-pays. This is why it’s important to take note of the type of insurance plan a patient has as well as follow up with that insurance company if a bill is left unpaid for an extended period of time.  

Once you’ve submitted a claim to a vision care or medical care plan, schedule a reminder to check up on your recently submitted claims should you not receive your due fees. This can be easily done by marking a calendar once a month or once every few months, or by using a clearinghouse to help handle your billing. Following up on claims that’ve not been processed out can also assist in finding out whether that patient’s specific policy is going to handle part or all of the payment, if there’s more information regarding the claim needed, and help you determine whether you need to bill the patient for an updated balance.  

Need Additional Assistance Managing Your Claims? 

If you’re still not seeing a return on fees you’re owed, implementing a clearinghouse to help handle all billing is recommended. This can help reduce potential loss in revenue due to claims being left unpaid and slipping under the radar unnoticed, and it can assist in getting you paid faster. Additionally, a clearinghouse like Apex EDI can help streamline filing claims so that vision and medical claims are verified before being submitted. This can be beneficial when trying to determine who to submit a claim to first, and it can offer patients a more accessible understanding of whether they need to pay anything following the claim’s processing.  

o make sure your optometry or vision care practice is staying on top of managing claims, keeping up with billing, and receiving the money due for your services, we’ve created a user-friendly and fully integrated clearinghouse for all of your medical and vision care claims. To learn more about our OneTouch® solutions at Apex EDI and how they offer you an easier, less expensive way to process claims, please schedule a live, personalized, and free demonstration of our medical billing software. 

“I just wanted to let you know we are seeing payments and the turnaround time is AMAZING! Apex is allowing us to collect so much faster than before, and our over 60 days receivables are down by 23%.”

Bethany Cassar, Complete Eye Health



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