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Routine vs. Medical Eye care in Houston, TX

Having your eyes examined on a regular basis is essential to having healthy vision for life. For this reason, it’s necessary to understand what benefits your insurance offers and how they can affect your care so you know what to expect with billing. It is ultimately up to you to be aware of what your plan covers. At Eye Excellence, we want to help the residents of Houston, Missouri City and the surrounding areas of Texas learn more about how your visits may be handled by your insurance company.

The benefits provided by your insurance can depend on the purpose of your appointment. How you describe your problem to your eye doctor will allow us to define it as either “medical” or “routine.” The symptoms you experience and the exam itself ultimately decide how we code your visit and bill your insurance company for it.

Billing for Routine Vision Examinations vs. Medical Eye Examinations

Medical and routine eye exams are different and understanding that difference can be tedious. Fortunately, there are a few key differences between medical and routine examinations that will affect the insurance billing process.

Q: What is a routine eye exam?

A: According to insurance companies, routine visits, also called annual visits, involve screening for eye problems, updating eyewear prescriptions and having eyesight checked.

Q: Does Medicare cover routine exams?

A. Medicare is not allowed under the law to cover routine visits or vision checks for eye prescriptions. If you have Medicare, you can still have these services performed, but you’re liable for 100 percent of the cost at the time of your visit.

However, in some cases, individuals with Medicare may possess special benefits that do pay for routine eye care visits via supplemental or secondary insurance. Be aware that these policies are subject to change, so you’ll need to stay up to date with what your specific plan covers.

Q: What is refraction? Does Medicare cover it? Does commercial insurance?

A. Refraction is the name of the procedure used to find out what your eyeglass or contact lens prescription needs to be. This process typically involves presenting a patient with a variety of different lenses. Two options are given at a time and the patient is asked to decide which image is clearer. This method helps determine the strength of the lens or lenses that will provide the best results.

Unfortunately, because refraction isn’t considered medically necessary under Medicare’s rules, it will not pay for the cost of this procedure. However, patients who have either private (commercial) vision insurance or Medicare supplemental insurance may have this service covered.

It’s important to note that your policy is solely a private agreement between your insurance provider and you. It is not an agreement between your doctor and insurance carrier. Furthermore, just because a procedure or treatment is covered by your policy doesn’t always mean the company will pay for the entire cost. A variety of insurance policies requires you to pay a portion of the cost, such as a deductible or co-pay, before they cover the rest of the cost.

If you have commercial insurance, it’s strongly recommended that you check with your provider before visiting our office to find out the following information:

  1. Whether you have vision benefits and what those are.
  2. Whether our doctors accept your particular plan.
  3. If refractions are covered.

Q: What if a patient has both medical and vision insurance?

A: The type of insurance that gets billed is determined by the purpose of your visit. If you need medical care, are having eye health issues or are visiting for a current health problem, these visits are medical in nature and will be charged to your medical insurance provider. However, if your appointment is for screenings, checkups or updating prescription eyewear, these are classified as routine procedures. As such, they will be billed to your vision insurance provider if your doctor accepts plans from them.

Q: What if a patient visits for a routine exam and the doctor discovers a medical eye problem? Can this be billed to medical insurance?

A: If you visit for routine care, we are not able to bill your medical insurance carrier for the visit if a medical problem is discovered. In these situations, one of two things will happen:

  1. If you have vision insurance and your doctor accepts your plan, your vision insurance will be billed.
  2. If neither of the above is the case, you will be responsible for paying the full costs of the exam on the day of your visit.

However, if you make a separate appointment to treat a medical eye problem discovered during your visit for routine care, it will be billed to your medical insurance at this time.

Q: Can both vision insurance and medical insurance be billed in the same visit?

A: This is possible in certain cases. For instance, if you visit for a medical eye condition and receive refraction during the same appointment, some vision insurance providers will cover the refraction while medical insurance picks up the rest of the bill.

It’s up to you to find out whether your vision insurance lets refraction be billed as a separate procedure during a medical visit. If your vision policy doesn’t cover refraction during a medical visit, you must either return another day for the refraction or pay for the refraction separately out of your own pocket.

At Eye Excellence, we have only one priority: to help you achieve better vision for a happier and healthier life. If you live in Houston, Missouri City or the surrounding areas of Texas, contact us today to schedule an appointment to learn more about the differences between routine and medical eye care.

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