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!