Which Insurance Do I Bill?

The patient’s “reason for the visit” determines which insurance is billed. So, if a patient presents with a refractive, non-medical reason for his visit, his vision plan receives the bill for the encounter. If the patient presents with a medical complaint, such as “here to get my diabetes checked,” his medical insurance receives the bill for the encounter. If he presents with both, we may coordinate the benefits from both insurances (if there is a provider for both) for services rendered.

Another scenario: If a patient presents for a vision exam and requires a spectacle prescription update, his vision carrier gets the bill for the encounter (ex. 92xxx or 99xxx — depending on the contents of the medical record — + 92015 would be billed to the vision plan). If you order medical testing during that visit, such as fundus photos (92250), if medically indicated for diabetic retinopathy, his medical carrier may be billed for that testing only (92250).

This is one scenario, but it is also acceptable to have the patient back at a future date to monitor his diabetic eye health and perform any additional medical testing if indicated. (Ex. order procedure: diabetic work-up, including fundus photos, in three months). That order from the patient’s previous encounter becomes the reason for the visit when he comes to the office for that testing.

Many different scenarios may occur, however, the reason for the visit determines which insurance receives the bill for the encounter.

Regardless of the scenario, a front-staff member should discuss this with the patient prior to the visit. This way, patients understand the difference between their insurance plans at the outset, preventing any potential confusion or patient complaints, while also educating them that you provide both vision and medical eyecare services. We recommend explaining the “why” to every patient when we “order visits and/or procedures” for them. This helps patients understand the differences between medical necessity and vision examinations. Patient education forms that show the difference between the two insurance types also help improve patient understanding of why a particular carrier is billed.

What You May Be Missing

The following is a list of the most prevalent medical eye conditions, keeping in mind that the median patient volume for an optometry practice is 3,100 patients per year.

1. AMD. Using the liberal definition of AMD (i.e., all patients with significant drusen in the posterior pole, with or without visual loss), it is estimated AMD prevalence is greater than 20% of the population older than 60 years. A more rigorous, population-based survey with a definition that requires the presence of either late atrophy and/or choroidal neovascularization results in an incidence of 0% at age 50 years or younger, 2% at 70 years, and 6% at 80 years, says a MedScape article. Using the prevalence of 20% of patients older than age 60 and the fact that the average amount of AMD-related visits per year is two (but again, this is determined by medical necessity), the annual practice revenue for AMD would be $90,520 for visits alone. If you factor in OCT ($46.21 per test) and fundus photography ($79.17), this figure would be even higher depending on the frequency of testing.

2. Dry eye disease (DED). An overall summary of data suggests that the prevalence of dry eye is somewhere in the range of 5% to 30% in the population aged 50 years and older, says the 2007 Report of the International Dry Eye WorkShop. If we also take into account patients who may suffer from ocular discomfort from contact lens wear and allergy patients who may suffer from DED, this number may be even higher.

Let’s say the incidence of DED in our “typical” practice is 25%. That means roughly 775 of your patients have DED. The average reimbursement per visit for these patients is $73. (This figure is for illustration purposes only, based on the Medicare Allowable fee for code 99213.) The average number of DED-related visits per year is three (but this is determined by medical necessity), bringing the annual practice revenue for DED to $169,725 for visits alone. This dollar amount does not include additional procedures and products that can be used to maximize treatment. For example, temporary and permanent punctal occlusion can add additional revenue of $229.44 ($152.96 for first plug, $76.48 for each additional plug) per patient.

3. Ocular allergy. Ocular allergies are often underdiagnosed and undertreated. In an older patient population, the prevalence of ocular allergy is 15% to 20%, but more recent studies reveal rates as high as 40%, according to October 2011’s Current Opinion in Allergy and Clinical Immunology.

If we used a 20% prevalence rate, about 620 of your patients have this condition. The average reimbursement per visit for these patients is also $73, according to Medicare fee data. The average amount of ocular allergy-related visits per year is two (but again, this is determined by medical necessity), making the annual practice revenue for this condition $90,520 for visits alone.

4. Glaucoma/ocular hypertension (OHTN). The incidence of glaucoma is 2%, while the frequency of OHTN is 8%, according to recent studies in Archives of Ophthalmology. That means an average of 310 patients in your practice have either condition. The average reimbursement per visit for these patients is $73 as well. The average amount of glaucoma-related visits per year is four (again, this is determined by medical necessity), bringing the annual practice revenue for these conditions to $90,520 for visits alone. If you add special ophthalmologic testing for glaucoma, however, you’d add another $314.88, which includes OCT ($46.21), pachymetry ($15.40), gonioscopy ($27.94), threshold visual fields ($65.20) and fundus photography ($79.17). The frequency of any of these tests in a given year is based on medical necessity, and some insurances may have their own frequency limitations. Also, keep in mind that more patients than are mentioned may be at risk for these conditions due risk factors, including high IOP, cup-to-disc ratio, family history, age, central corneal thickness and race.