Vision Medical Billing & Revenue Cycle ManagementVision Medical Billing & Revenue Cycle Management

What makes vision billing difficult?

Eye care practices bill two different kinds of coverage: routine vision plans for eye exams and eyewear, and medical insurance for eye disease and injury. Choosing the wrong one at check-in sends the claim to a payer that won't cover it. Diagnostic testing and eye surgery add their own coverage and global period rules on top.

What are the most common vision billing pitfalls?

• Medical vs routine vision plans. A visit for a medical complaint or condition is billed to medical insurance; a routine exam for glasses or contacts goes to the vision plan. The reason for the visit, documented at check-in and in the note, decides which plan pays.
• Diagnosis linkage. Each test and visit must point to a diagnosis that supports it, such as a retinal exam for a patient with diabetes. A test linked to a routine or unrelated diagnosis is denied as not medically necessary.
• OCT and visual field testing. Imaging such as OCT and visual field tests have coverage policies that limit the diagnoses and how often the test is paid. The interpretation and report must be documented for each test.
• Global periods for eye surgery. Cataract and other eye surgeries carry a global period that includes routine postoperative care. Visits for unrelated problems during that period need the right modifier, and shared care between surgeon and optometrist is billed with modifiers that split the global payment.

What causes vision claim denials?

The most common causes are a claim sent to the vision plan when the visit was medical, or the reverse, and diagnostic tests linked to a diagnosis that doesn't meet coverage policy. Tests billed more often than the plan allows and postoperative visits billed inside a global period also come back denied.

How do you handle eligibility and prior authorization for vision care?

We verify both the routine vision plan and the medical plan before the visit, so the front desk knows which coverage applies and what the patient may owe. Where a medical plan requires approval for surgery or certain testing, we request it ahead of the scheduled date and track it to the claim.

How are vision claims coded and submitted?

Each claim is checked for the right exam code for the plan type, diagnosis linkage for every test, and modifiers for laterality, global periods and shared postoperative care. Routine and medical services from the same day are separated onto the claims for the plans that cover them.

How do you handle payment posting and AR follow-up for vision care?

Payments from vision plans and medical insurers are posted by line, so materials, exams and tests can each be reconciled. Unpaid claims are worked by payer and filing deadline, and claims sent to the wrong plan are redirected quickly rather than left to age.

Do you handle credentialing and enrollment for eye care providers?

Yes. We help enroll optometrists and ophthalmologists with medical plans and vision plans, which credential separately. Keeping both enrollments current lets a provider see patients under either kind of coverage from their start date.

How does onboarding work for an eye care practice?

Most practices are onboarded within two to four weeks, depending on the size of the practice and how quickly payer and system access is set up. We work within your existing practice management system, so your doctors and opticians keep the tools they use today. See all the specialties we support.

Frequently asked questions

When is an eye exam billed to medical insurance instead of a vision plan?

An eye exam is billed to medical insurance when the visit is for a medical complaint or condition, such as eye pain, an injury, or monitoring diabetes or glaucoma. A routine exam to check vision and update glasses or contacts goes to the vision plan. The documented reason for the visit decides which plan pays, so we confirm it at check-in.

Why do OCT and visual field claims get denied?

OCT and visual field tests are denied when the linked diagnosis isn't on the payer's coverage list, when the test is billed more often than the policy allows, or when the interpretation and report are missing. We check the diagnosis and the patient's testing history against the plan's policy before submission, and correct and resubmit denials with the report attached.

What is a global period for eye surgery?

A global period is the time after surgery during which routine postoperative care is included in the surgical payment. Visits for the same surgery during that time aren't billed separately. Visits for unrelated problems can be billed with the right modifier, and when an optometrist provides the postoperative care, surgeon and optometrist each bill their share with modifiers.

Can one visit include both routine vision and medical services?

Yes. A patient may come in for a routine exam and also need care for a medical condition. The routine part is billed to the vision plan and the medical part to the medical insurer, each with the right codes and diagnosis. We separate the services onto the correct claims so neither plan denies the visit for the other's services.

Do you work with both optometry and ophthalmology practices?

Yes. Optometry practices usually bill more routine vision and diagnostic testing, while ophthalmology practices bill more surgery and global period care. We set up the plan rules, modifiers and testing policies each practice needs, verify both kinds of coverage before visits, and work unpaid claims with each payer until they are resolved.

Related services: eligibility and benefits verification; claim creation and submission; payment posting; denial management; provider credentialing and enrollment; accounts receivable follow-up.

Related reading: why medical claim denials are rising; payer-published denial rates vs your own.

Related specialties: primary care; orthopedics.