What is included in a routine eye exam or annual eye exam?
A routine or annual eye exam is PREVENTION-focused, not problem-focused. It usually takes place once a year. It may include the following:
- Diagnosis and treatment of non-medical complaints like:
- Nearsightedness (Myopia)
- Farsightedness (Hyperopia)
- Need for bi-focals (Presbyopia)
- Astigmatism
- Past ocular, medical, social and family history
- Review of medications (excludes new medications or medication changes)
- Counseling/anticipatory guidance/risk factor reduction of possible eye issues/diseases
Will my provider address only what my health plan covers for a routine eye exam?
Your provider does not know your health plan benefits and sees many patients with various insurance plans throughout the day. You are responsible for knowing what services are covered under your plan.
Review your Summary of Benefits prior to your routine eye exam or call your insurance plan’s Customer Service, on the back of your card, for your benefit information.
What can I do to help ensure I receive my routine eye exam benefit?
You can take the following steps to help ensure your exam is billed as routine and not medical.
- When scheduling your routine eye exam with your provider’s office, use the terms “routine eye exam” or “annual eye exam,” not “check-up,” which implies checking up on a specific eye problem(s).
- When you talk with your provider, let them know you are there for your routine eye exam.
- If you have chronic health problems, such as high blood pressure, diabetes, cataracts, dry eyes, or new concerns that you wish addressed during your routine eye exam, understand that those are medical concerns. You may have a charge related to the treatment of that specific problem. Or, you may have to schedule another appointment to address specific concerns. If you wish to address your other medical problems or new concerns, please notify scheduling of this as well.
- Please do not save up all your health concerns for your routine eye exam, as they may require additional diagnostic visits or services not covered by this exam.
Vision Plans vs. Medical Insurance
Thrive With Vision does NOT participate in vision plans. If you have a vision plan, your medical insurance may or may not cover a routine examination. Please call your medical insurance company to find out if they will cover a routine examination if you have a vision plan that we do not participate in.
Why did I receive a bill after my routine eye exam when it was supposed to be covered at 100%?
The exam is prevention-focused, not problem-focused. If you have a new health problem or other diagnoses that need to be addressed during your routine eye exam, e.g. high blood pressure, diabetes, cataracts, dry eyes, etc., your provider has to bill the exam as a medical exam, not a preventive exam. A medical exam is applied to your deductible and coinsurance. It is important to note that your healthcare team is mandated to bill according to CMS (Centers for Medicare and Medicaid) billing and coding guidelines federal regulations. Your provider cannot change diagnosis codes to help get your claim paid – this is insurance fraud.
Questions for your insurance company, to help you determine what your total costs will be, based on your specific plan.
What does my plan cover?
Will a problem-based office visit be covered? How much will I end up paying for testing or treatment of a particular medical condition?
How much will I need to pay?
What are the co-pays, deductible, co-insurance responsibilities, and other out-of-pocket costs?
Are there limits regarding what my plan covers?
Are there limits to the number of routine eye exams, office visits, and routine tests within my plan?
Important information from Medicare
Your provider may recommend you get more services more often than Medicare covers or may recommend services that Medicare does not cover. If this happens, you may have to pay some or all the costs. Remember to ask questions to understand why your provider is recommending certain services and whether Medicare will pay for them.
Remember, your provider’s main goal and responsibility is to provide every patient with the best possible service and care, based on their needs. The provider, while diligent about appropriate medical coding and billing, is not responsible for ensuring full insurance coverage.
Questions?
If you have additional questions, please contact Thrive With Vision’s billing office at (320) 733-8844
Or, Fairview Range Billing (Thrive With Vision’s third party biller) at (800) 450-0225