Medical vs Vision Insurance | Helmus Optometry

Which gets billed when?

One of the most challenging billing issues for an eye doctor's office is to determine whether your visit is for a medical reason (cataracts, glaucoma, eye pain, eye injury, lid lumps and bumps, flashes and floaters, macular degeneration, dry eye, etc.) or a wellness vision exam to determine your prescription for glasses, contact lenses and screen the health of your eyes to make sure you do not have any eye problems or eye diseases you may not be aware of yet.

More than just once a year

Sometimes it is appropriate to schedule separate visits to accommodate both your routine eye care needs (glasses, contacts) and medical eye needs (glaucoma follow-ups, dry eye evaluation and treatment, etc.) on different days.

Our goal... is to bill appropriately based on the reason for your visit.

If you call us with any of the following issues, we will cater the exam to medical eye care:

A medical eye problem (abrasion, red eye, swollen lid, foreign body, flashing lights/floaters, pain, dry eye, glaucoma, cataracts, macular degeneration, etc.)
Sudden change or loss in vision
Another doctor (ophthalmologist, primary care, endocrinologist, rheumatologist, etc) asked you to see us for an exam
You've started medications that can risk your eye health

In these instances, we would bill your medical insurance the same way any other specialist health care provider would. You would be responsible for copays, deductibles, and coinsurance.

Medical Insurance

EXAMPLES: Medicare, Aetna, BCBS, Cigna, etc.

Medical insurance will be used for medical eye health visits (cataracts, glaucoma, eye pain, eye injury, lid lumps and bumps, flashes and floaters, macular degeneration, dry eye, etc).

Most medical insurance plans do NOT pay for eyeglasses for contact lenses. Medicare patients are responsible for their refraction fee if a prescription for glasses is desired. Medicare patients are also responsible for exam fees if their deductible is not met at another doctor's office already for the calendar year.

Some medical plans may have an actual reimbursement direct-to-patient. It is the patient's responsibility to know whether they have this benefit and file directly with the medical plan for reimbursement. We will assist with appropriate receipts for submission.

Vision Plans

EXAMPLES: VSP, EyeMed, MES

Vision Plans (VSP, EYeMed, MES) are NOT truly insurance. They cover a routine vision exam and refraction for glasses, contacts, and inspection of the internal and external eye health in a healthy person without known eye disease.

Vision plans provide discounted fees for contact lenses and glasses. Some plans are better than others. We will help you maximize your savings. In order to do this, you must know you plan and present it ahead of being seen for your exam.

If you have a vision plan, it is your responsibility to inform our staff at the time of scheduling the appointment so that we may assist you in understanding your benefits.

Unanticipated Same-Day insurance billing change

Rarely, a routine eye wellness visit must be converted to a medical visit if an incidental and urgent eye problem is discovered during your vision exam.

Examples:

Dangerously high eye pressure that needs immediate testing and treatment to prevent irreversible vision loss
Dry eye and damage to the cornea that would prevent us from obtaining a reliable refraction for glasses or performing a contact lens fit.

Medical vs. Vision Insurance

Which gets billed when?

More than just once a year

Our goal... is to bill appropriately based on the reason for your visit.

Medical Insurance

Vision Plans

Unanticipated Same-Day insurance billing change

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