Summit Eye Care: Insurance – Gotta Love It!


Thirty-two years ago, I began a career in ophthalmology.   Everything was simpler then: handwritten charts, two main phone lines, and patients signed an insurance form on their way out.   EVERYTHING HAS NOW CHANGED!  There are many lines to be answered, records are electronic (but we continue to generate a lot of paper), and insurance is anything but simple.

Ophthalmology is the ONLY medical specialty which deals with two types of insurance—Medical and Vision.  If seeing an eye care provider, one might ask why all expenses would not be covered under the “Vision” plan?    Good question, but that is not the way it works. I will make an attempt to differentiate the two from information I have obtained over the years.

The portion of the exam to obtain a prescription for glasses (refraction) was included in the reimbursement from insurance companies many years ago.    However, the medical insurance companies decided that this part of the exam is not necessary when it comes to treating “eye diseases.”  Reimbursements were decreased and “Vision” Insurance plans such as Superior, VSP, Spectera, etc. were developed.   Now we have “medical plans” and “vision plans.”

This would not be an issue for eye care providers or patients, except for the fact that the Vision Carriers’ claims cannot be filed to cover the routine eye exam on the same day as a “medical” problem claim such as diabetes, glaucoma, dry eye, infections, etc. is being filed. This means the patients must make two appointments – one for their medical and one for their routine appointments – on different days. Medical claims involve copayments and sometimes deductibles.   Vision plans often just have a copayment.

Tips for ensuring the correct filing & payment of benefits:

1) Bring all insurance information to the appointments.  Include both Vision and Medical cards and any necessary paperwork.

2) Make it very clear what your goal is for the visit.   If the visit is about receiving a prescription for an updated pair of glasses and/or contact lens, let the receptionist know.  If the visit is about your red, itchy, irritated eyes, the visit will be filed as medical and no “routine” care will be given on that visit.

3) Do not “change” the reason for the visit. You cannot change the purpose of the visit in midstream or dispute the insurance coverage when it is determined there was a deductible or high copayment.  At that point, it is too late to reverse the claims.

4) Prior to visits, determine if the provider’s office is on your insurance provider roster.  If there is a question, please call the provider’s office to inquire.   Give all the information.   For example, your medical insurance may be Insurance XYZ Company, but the vision carrier may be Insurance ABC Company.   Both pieces of this information are required for the provider’s staff to dispense correct information.  Just because the provider is in-network with Insurance XYZ, he/she may not be for Insurance ABC.

Insurance is complicated and can be a challenge, but with a little prior planning, it can be navigated with success. Remember, the providers do not make the insurance rules.  The carriers create the guidelines; and physicians and their staffs interpret and adhere to the best of their ability.

Summit Eye Care is happy to assist anyone with their eye care needs and will make every effort to collect the correct payable benefits for our patients.


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