There are essential differences between vision and medical insurance that aren’t necessarily common knowledge. However, understanding them can help eye care professionals avoid billing and coding errors.

ECPs considering accepting medical insurance—whether on an in- or out-of-network basis—should first ensure they and their staff understand these crucial distinctions. This will help you avoid issues with claim submission, ensure the best patient experience and might even be a great topic for your eye care practice blog!

Whether you plan to work with medical insurance or not, it's going to be helpful to know the basics.

The differences between vision and medical insurance

The foundational differences between vision and medical insurance illustrate why it’s so important for ECPs to bill the correct plan. Let’s dive into contrasts between vision and medical coverage:

What vision plans cover vs. what medical insurance covers

The primary distinction between each sort of plan is coverage. Vision plan coverage is more limited than medical insurance coverage.

Vision plans cover “routine” refractions and eye exams. Essentially, any appointment that's not medically necessary and includes either or both of the aforementioned services.

Medical insurance is used to cover medical treatment. Any appointment considered routine does not qualify as medical. Additionally, medical coverage does not include exams or diagnoses for myopia, hyperopia, astigmatism or presbyopia.

How frequently vision plan coverage may be used by patients

Vision plans place annual limits on how frequently coverage may be used.

Usually, vision plan coverage can only be used one time per calendar year. Patients may receive an eye exam and refraction as part of the typical plan. However, each service must be provided on the same day. If an eye exam is performed on a Monday, the patient will not be eligible for refraction the following Wednesday.

Medical coverage is different. It can be used multiple times per year as long as it is applied to medically necessary care. Typically the patient pays some out-of-pocket expenses in copays or medical deductibles for the treatment rendered.

ECPs can bill medical insurance only for a medical necessity

This one may seem kind of obvious, but medical insurance may only be used for medical necessities. Vision plans, meanwhile, is designated for routine eye exams and refractions. These appointments are not usually deemed medically necessary.

For example, if a patient asks: “Does medical insurance cover eye exams?” You can confirm it does not.

What does medically necessary mean? 

Medically necessary is a pretty ambiguous term. Defining what it means in practice can be difficult without some additional criteria. Luckily, a Review of Optometric Business article lays some rules for medically necessary treatment. The care must:

• Align with generally accepted standards of medical practice.
• Be clinically appropriate and effective for the patient’s condition. 
• Not be provided simply for the convenience of the patient or O.D. 
• Not be more costly than an alternative treatment that would produce the same diagnostic results.

Can an optometrist bill medical insurance?

Given all the distinctions between medical and vision plans, can an optometrist even bill medical?

Yes! An O.D. can certainly bill medical insurance when a patient comes to the practice with a medical condition to be treated. As long as the patient’s treatment is medically necessary, medical coverage may come into play.

Look for a sign or symptom that requires medical treatment

Ultimately, a medical sign or symptom that necessitates treatment is the only care that can be billed to medical coverage.

If a patient comes in showing such a sign or symptom, it’s best to use medical insurance for that visit and save vision coverage for a later appointment, according to a separate ROB article.

After all, in this instance, there’s good reason to use medical coverage. When the patient is healed he or she can come back to use vision plan coverage for a routine exam and refraction. This provides incentive for the patient to return and use his or her vision benefits before the year ends.

What if the patient has insurance you’re not in-network with?

Many ECPs treat at least some patients who carry insurance plans they’re not contracted with, and some even remain off insurers’ panels altogether. Do the same rules apply?

For the most part, yes! Medical coverage will still require medically necessary treatment. Vision coverage will still have limits on how frequently it may be used and will apply only to routine exams and refractions.

Similar to vision plans, with medical coverage the difference between in- and out-of-network insurance will be the process: Eligibility verification, claim filing and such. If you already know how to be an out-of-network provider, this shouldn’t be much of an issue.

Accepting medical insurance at your practice

Medical insurance can present problems for practices that aren’t prepared. However, if you and your staff are ready to begin accepting medical coverage it can be a boost for business.

You’re able to treat more patients for a wider variety of symptoms and conditions when your practice works with medical payers. That means more opportunity for you to grow your practice over time.