Vision insurance, refraction fees, and should I have an optical shop?

Vision insurance is different from health insurance. Health insurance typically does not cover “routine” exams (with very few exceptions with the Z01.01 code as primary). Not surprisingly, health insurance typically does not cover refractions. Most ophthalmologists in our google group who refract (retina and plastics usually don’t) charge an extra refraction fee, usually $30-55 depending on your location. I charge $40 because that is what we charged at our group practice. You might want to phone around as a pretend customer to see what practices in your area charge. You never want to be the lowest person in town- the patients who pick you based on price rather than your reputation are NOT the ones you want to build a practice on!

If you are not in network for vision insurance, you will want the patient to sign a form indicating they understand that the refraction is not a covered service and that an additional fee is necessary. This can be part of your new patient financial policies form. My group practice actually had a separate form. We always explain this policy when the appointment is made (if the patient requests a glasses prescription), as well as when the patient is in the office. We also hand the refraction to the receptionist to collect from the patient before the refraction is given to the patient. If you don’t, patients will unfortunately try to skip out in paying.

We always send the 92015 refraction code to the insurance company; most of the time we get back a zero EOB (for example, traditional medicare doesn’t pay for refractions). We occasionally have a medicare advantage plan, medicaid plan, exchange plan, or tricare pay for refractions. Sometimes it’s based on age or even whether or not the patient has diabetes!

In contrast, vision insurance does not cover health problems but does cover routine exams and includes the refraction fees. A quick google search for a UHC vision plan showed yearly premiums of $120 with a $10 copay for exam. At these premiums, to make a profit the plans are typically paying $30-50 for the once a year exam, and maybe a $50 frames benefit that they advertise as being worth $75. Many offices choose to be in network because not because they expect to make a profit from the exam, but rather for additional testing (such as an optos photo for $40 or upsell of frames).

Patients are often confused by the difference between vision and health insurance. Many patients think that even if they have cataracts, vision insurance will pay for their cataract surgery. We explain to them that we are a specialist office just like a cardioloigst, and if they choose to be seen in our office it goes through their health insurance. Some typical vision insurance plans are Avesis, VSP, Spectera, and EyeMed. I have trained my front desk to know what these plans are and to tell patients we are out of network, and ask what their health insurance is.

Some ophthalmologists choose to accept (join the network) for vision insurance. It is a question of what your goals for your practice are, and I will discuss the pros and cons. My unscientific estimate is about 20-25% of the comprehensive ophthalmologists in our google group are in network for vision insurance. If you want to be in network for vision insurance, you need to have an optical shop. We are about to talk about real estate, but you’ll probably need another 200-300 square feet. There are firms that will assist with your optical buildout, design, and furniture. You’ll have to hire a part time optician or train your staff to cover the optical.

Both Ho Sun and I chose not to have an optical. Personally, I hate refraction, don’t really know how to do contact lens exams, and can’t stand seeing young patients without health problems. Ho Sun felt that having an optical might potentially limit his referrals from optometrists. In fact, when patients phone in and are under 55 without medical problems, no ocular complaint, and just want a routine exam, we decline to schedule them. I also don’t want any confusion between the two types of insurances for my patients, or for them to try to get me to bill their cataract evaluation under their vision plan.

But other people on our thread want to be the busiest practice in town, or feel that they can make the profit margins for the optical work well enough to make up for the poor reimbursements from the plans, or that if they have happy vision patients they will bring their family members with medical problems to be seen. Every area and locality is different- in some areas where there is a oversupply of ophthalmologists, some of them will choose to join these plans just to bring more warm bodies into their practice.

If you choose to take vision insurance, decide and have a plan for how you will make it work from the get go. I’m not sure that deciding to join vision plans out of desperation at month three because you’re only seeing four patients a day is a good idea. Once you get busy, which all of us will become eventually, it’s much harder to “undo” your optical and go out of network for vision to concentrate on surgery and health problems.

Some practices that accept both vision and health insurance bill the health insurance if they find a medical problem. According to the research I’ve done (see this link and this link) it depends on the chief complaint; even if you find end stage glaucoma if the chief complaint was “routine eye exam” you bill the vision insurance first. Sometimes you can bill vision insurance for the exam and health insurance for testing. I’ve heard of practices bringing in patients under the guise of a vision exam and then without notifying the patient billing the health insurance, which seems shady to me.

For me, my practice is growing nicely and I have all of my happy cataract postop patients tell their friends and family about me. I would rather grow a practice focused on cataracts than load my practice with patients with issues that I don’t want to deal with, like fitting contacts. Although if I ever move into a office with more space and hire an optometrist, I’d consider building an optical and having the optometrist credential with vision plans. But for now, I’d rather focus on medial problems and cataract surgery. The beauty about going solo is you can choose whichever route you want!

7 thoughts on “Vision insurance, refraction fees, and should I have an optical shop?

  1. You get independent by being a comp Oph,get an optical ,fit the damn contacts be a physician ,not a surgical technician,,thats what the ods want you to be,, and forget mollifying the od referrals,they do not refer to you because you are good and honest ,they refer to MDs who concede to the quid pro quo.Diagnose their lid retraction ,their amaurosis,,their rosacea,be a physician ,thats why you went to medical school.and you will survive and thrive.
    Stop reading the rags, “Surgery News” they mislead the young MDs who think the way to thrive is ,collaborate”
    If you are going to stay “solo” ,make your mark as being the best medical doctor they ever visited.You are a primary care physician,they see you forever,they trust your advice.A day does not pass that I do not ask my patient “have you gotten your shingles vaccine ” and if not why not …thats what a “caring physician ” does,,
    From the son of a solo Oph and a solo ophthalmologist for many years I can assure you,your best path is to be a physician first not a technician ,what ods want you to be ..

  2. I agree. I’m an employee in a group practice that has an optical shop, and it would be so much easier if we just sent people out for their glasses and CTL fittings. It seems like a lot of hassle for not a lot of benefit.

  3. I wholeheartedly agree with Ralph. You should never let your fear or concern about losing or angering a referral source compromise your clinical judgment or decisions. Just be a honest and competent doctor, and patients and referrals will eventually seek you out. You can be successful without selling yourself out to questionable arrangements. Optom referrals probably consist of less than 3-5% of my practice. I refuse to co-manage anything. However, I still have chosen not to open up an optical because I already have too much on my plate, and my office doesn’t really have the space for it. Yes, I am probably giving up on some income, but not having an optical also allows me to focus on being an M.D. I also don’t want to hire more employees either.

    As you can see, I was naive and ignorant about the truth of private practice. I’ve been fed all this nonsense, and it’s very sad to see the establishment perpetuate these misconceptions. Just because group practices have no idea how to run a practice properly without selling out doesn’t mean it can’t be done. Despite solo ophthalmology being 26% of all AAO membership, when YO programs like “the real world of ophthalmology: telling it like it is” consists of a panel of 3 group practice and 2 academics ophthalmologists, how else can residents and fellows perceive things otherwise? Look at the Youtube videos on YO. Most “experts” make fun of us, saying that we are a dying breed or dinosaurs, despite having absolutely no idea what they’re talking about in this department. They should just stick to letting their office manager mismanage the practice and quietly embezzle co-pays and deductibles over 20 years.

    Thankfully, the AAO is aware of how solo practice has been misrepresented, and I appreciate the fact that they are motivated to rectify the situation.

    Ho Sun

  4. Ho Sun,lets work on the YOs issue.Speak to Gail and Andy ,lets get the MYF program for YOs to put you ,Andy et al on the program.26% is a formidable number.Interesting fact,2016 the YO survey asked “why are your State Soc membership lower than the gen membership # ,,Ans : afraid it might damage optometric referrals as they grow their practice..Now think about that,the AAO has the SSF “100% Confidential ” to PROTECT your name from referring ods ,and the YOs are afraid to join State societies because the Advocacy label gets hung on them.Optometry referrals ,even if you dont comanage paralyzes this profession ,,,economic extortion ..98% Oph in AAO,42% join state socs…
    Until we break the bonds tied to referrals ,we are doomed to their advocacy successes.
    Academic centers are likewise not immune from caving to comanagement ,just ask your colleagues in the Institutions who do not comanage(some of the best ),they will tell you,the others are killing them financially..while teaching residents its OK to fee split..
    Solo folks often make their own minds up ,groups make the decisions generally for the YOs in the practice..

  5. Ralph,

    You should join our solo eye docs group. If you already contribute to SSF, joining should cost you nothing. We already have AAO’s ears, and they are implementing changes for next year. We will have more solo practice representation with the YO. Appreciate your comments. Thanks.

    Ho Sun

  6. i take vision plans, as a young Dr trying to build a practice most pts enter the eyeword for RTE checks under the vision plan. You are not paid much and sometimes the optical headaches with reimbursement can be frustrating. That being said, I’ve been able to sign up cataracts, glaucoma testing and other medical f/u s under their health insurance, this has helped me grow at a faster rate. If I only took medical I think my medical practice would be smaller as I have generated a decent amount of medical f/u after the RTE. We charge for CL evals and do offer optos to young healthy patients making the exams more efficient. Pts seen under medical insurance do sign a refraction fee and have the option not to have refraction. I have not had an issue with cataract referrals. I only use 54 and 55 modifiers for surgical care only and the referring Dr uses the post op code. This eliminates any financial interest. As long as the pts are referred back they have been happy.

    • Dr,regarding your Optos comments for young healthy patients,careful here ,you are paid for a comp exam that includes a dilated component,you are getting paid for such,then charging patients for a photo….not good.. ,masked as “convenience” ,faster exam..
      read the AAO 2016 Ethics Policy re use of 54/55,read the LCD ,it says “occasionally” ..

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