How to Check for Hidden Vision Plans in Your Patient's Medical Insurance

As an optometrist, we're dedicated to providing the best possible care for our patients, and understanding their medical insurance, especially regarding vision coverage, is critical for providing that care.

Uncovering Hidden Vision Plans

We know that medical insurance plans cover medically necessary eye care, but did you know that some medical insurances also cover routine vision exams? These "hidden" vision plans, often included within broader medical insurance policies, can significantly impact coverage. Providers who effectively navigate these plans can ensure their patients receive optimal care while also maximizing their optometry practice's revenue through strategic insurance billing.

Maximizing Revenue

My practice is in-network with Spectera, as are thousands of other optometry practices across the US. However, despite a large percentage of our patients having Spectera, we rarely ever bill them. Why? Because Spectera is the vision carrier for United Healthcare, and many United Healthcare plans include their own vision coverage. This means we can choose to bill either United Healthcare or Spectera (but not both) for a patient's routine visit. Currently, United Healthcare pays almost three times as much as Spectera, and both plans have zero copay for the patient. That makes it a pretty easy decision.

Navigating Insurance Coverage

Finding out which medical plans cover routine vision can be tricky. While some eligibility portals offer information, they're often vague on specific vision benefits. I prefer calling the insurance company's provider line for clarity. Specify that you're asking about routine vision benefits. They might ask for a CPT code (use 92015) and a diagnosis code (use H52.03). Ask the representative about the patient's exam copay, coverage limits, contact lens fitting, and eyewear coverage.

Billing Strategies

If I'm unsure, I usually bill the routine codes to the medical plan first. A paid claim indicates coverage for routine care, while a denial prompts me to submit to the vision plan. Maintaining a list of medical plans with routine vision coverage can streamline billing decisions and save time

Important Billing Tip

When billing medical insurance for a routine exam, ensure the claim only includes refractive ICD-10 codes. Any medical diagnosis codes will trigger the patient's regular specialist copay and deductible. However, if the patient presents with a medical complaint, remember to submit the exam to their medical plan, regardless of any routine benefits.

I hope this article has provided valuable insights into uncovering patient benefits that you may have been missing. Taking just a few extra minutes to explore insurance coverage could lead to a significant increase in your optometry practice's bottom line. If you have any questions, please don't hesitate to reach out to me. Your success is important, and I'm here to help in any way I can.

The recommendations in this blog post are based off of my own practice experience and not a guarantee of any income you will receive.

A Guide for Optometrists: Billing Humana Out-of-Network

Last August, I opened a new optometry office located inside a Walmart Vision Center. Our population is heavily Medicare and Medicaid, and we rely on medical billing for about 90% of our patients. A large number of our Medicare patients have Humana medical benefits and EyeMed vision coverage. With the current EyeMed reimbursement for Medicare Advantage patients at only $55, it is important to us that we bill the Humana medical plan for as many patient exams as possible.

Challenges with Humana Provider Networks

I was surprised when I reached out to Humana for credentialing, only to be informed by Humana Provider Relations that they had closed their networks to optometry and were not issuing any contracts for this specialty, which was not the news I had hoped for. Currently, we are in negotiations with Humana to become In-Network providers. In the meantime, we have been billing Humana using our patients' Out-of-Network benefits, which has proven quite successful. I'd like to share some tips on how to bill Humana Out-of-Network and still achieve better reimbursement than you would with EyeMed.

Key Steps to Effectively Bill Humana Out-of-Network

• Verify Patient's Coverage: Before providing any out-of-network services, it's crucial to verify the patient's insurance coverage. Contact Humana's provider services or use services such as Availity, TriZetto, or Office Ally to confirm the patient's eligibility, benefits, and any out-of-network coverage limitations. This step will help you determine the patient's financial responsibility and set appropriate reimbursement expectations.
  

• Pay Attention to Out-of-Network Benefits: When implementing these strategies, it's crucial to pay attention to the patient's out-of-network deductible. If the deductible is high, you might choose to bill the vision plan instead. Alternatively, for exams that are clearly medical in nature (e.g., for diabetes or cataracts), you can request that the patient pay out of pocket. In this scenario, you would still submit the claim to Humana, and the payment would count towards their deductible.

In the case of this patient, there was no deductible, co-insurance, or co-pay for either in network or out of network providers. This information was found on Availity.

• Obtain Informed Consent: Inform the patient about your out-of-network status and the potential financial implications. Obtain their written consent, acknowledging their understanding of the potential higher costs associated with out-of-network services. This step ensures transparency and helps avoid any disputes later on.
  

• Bill with Accurate Codes: When billing Humana for out-of-network services, it's important to use the correct billing codes. Ensure that you accurately document the services provided, including the diagnosis, procedures, and any relevant modifiers. Adhering to proper coding guidelines will help prevent claim denials or delays.
  

• Submit a Clean Claim: To expedite the reimbursement process, submit a clean claim to Humana. Ensure that all required fields are completed accurately, including patient demographics, provider information, and service details. Double-check for any errors or omissions that could lead to claim rejections.
  

• Consider Coordination of Benefits (COB) with EyeMed: If Humana denies the patient's refraction, you can submit the claim to EyeMed using COB. Some Humana plans are still eligible for EyeMed COB, except Humana Vision Insight and Humana Medicare. Follow the process of filing your claim with Humana first, then transferring the unpaid refraction to EyeMed using a CMS 1500 form.
  

• Billing Patients for Unpaid Copays or Deductibles: Unlike VSP, EyeMed only pays for the refraction code. It's important not to routinely waive copays or deductibles owed by the patient, as this is considered insurance fraud.
  

Billing Instructions for Humana Claims

Submit your out-of-network claims either electronically with Payer ID 61101

or by mail on a CMS 1500 form to: Humana Claims, P.O. Box 14601 Lexington, KY 40512-4601

Communication is Key

Effective communication with patients regarding the billing process is essential. Transparency builds trust and ensures patients understand the financial aspects of their care. Implementing these strategies can increase reimbursement for EyeMed/Humana patients, impacting your practice's bottom line. If you have any questions, feel free to reach out. I'm here to help!