Billing issues, to an extent, are expected in any physician or healthcare provider office. Most patients are in possession of both medical and vision benefits coverage, and this duality often causes confusion in ophthalmology offices. Certain procedures that are performed in an ophthalmology office should be billed as medical procedures, and do not apply to the typical vision coverage plans. The only way to combat the complexities of these billing issues is to gain an understanding of who is responsible to pay for which services, and even then the waters are murky.

Long story short: Medical plans are responsible for medical diagnoses and tests. Vision plans are responsible for routine exams and refractive conditions.

For example; both vision and medical coverage parties could be responsible for payment of an eye exam. In order to determine the nature of the eye exam, one must take into account a variety of factors including; chief complaint, diagnosis, and the steps or procedure taken in order to facilitate the exam. These office visits will be categorized as “routine” or “medical” depending on exam findings. Scheduled office visits that yield a diagnosis such as an astigmatism or farsightedness are billed to the patient’s vision coverage. Office visits facilitated to treat an acute problem with a diagnosis such as conjunctivitis are classified as “medical” and are billed as such. Insurance companies will often put more weight on the reason for an office visit – so the patient’s intent on getting treatment or just a “check-up” is a reliable checkpoint for determining who the responsible payer is.

Keep in mind that with this emphasis on chief complaint, that even if your ophthalmologist makes a diagnosis of a condition such as glaucoma during a routine office visit – your vision plan (VSP) will still be billed because you didn’t arrive with a legitimate medical problem. However; any visits made to follow up on this diagnosis will be billed to your medical coverage provider as long as they are established as related to your suspected glaucoma diagnosis. After the precedent is set with your vision healthcare provider, the responsible payer is determined by how you specify the reason for your visit. If you are seeing the ophthalmologist after this diagnosis has been made, and you want to ensure that your vision plan is billed, you must specify that you are there for a reason not associated with your medical condition. If you return to the ophthalmologist for a routine eye exam so that you can buy new glasses – it would be billed to your vision plan. As a patient, make sure you emphasize this to your care provider. As a provider or billing specialist, make sure you have clarification on the patient’s reason for the office visit.

Why the Distinction is Important

A partial understanding, or disregard of these billing regulations can lead to serious billing errors with criminal consequences. It is important to document thoroughly and have an understanding that the patient’s chief complaint or reason for the office visit is the determining factor – and that tests to evidence a medical diagnosis can only be billed to the medical payer after a new diagnosis. Accidental or otherwise, “double-dipping” into both payer pools is a problem that has presented itself a number of times. In the world of FWA – we are vigilant about documentation and ensuring that only the responsible payer is responsible for the bill. If a provider is charging both vision and medical plans for the same office visits, regardless of chief complaint – there is an issue. The provider must be educated or investigated in order to determine if fraud is being committed.

Plans who outsource their vision benefits should consider utilizing data analytics of paid claims data in order to identify trends or other signs of fraud, waste, and abuse. Provider documentation is also a key factor in identifying FWA. Providers should supply plans and auditors with documentation that is legible and thorough. Claims packages sent in for medical record review should include any consultation request forms, test orders, proper utilization of chief complaint, simple and concise coding that utilizing a mixture of E/M and eye codes. It could be useful for providers and billing specialists to keep a checklist of all required items in order to ensure that every chart is as accurate and reliable as possible.

For more information on helpful hints and tips for billing vision vs. medical plans, read through the BSM Connection for Ophthalmology.