In a busy eyecare practice, it’s easy to treat insurance verification as just another box to check, but overlooking the fine print can lead to costly mistakes. At OMS, we’ve seen firsthand how simple missteps in reading or communicating patient insurance benefits can result in claim denials, delayed payments, billing confusion, and frustrated patients.
Here are three real-world examples (based on scenarios we’ve encountered) that highlight why taking the time to thoroughly read and understand both vision and medical benefits is crucial to revenue success.
Example 1: Billed to Vision When It Should’ve Been Medical
The scenario:
A patient schedules an appointment due to blurry vision and eye strain. At check-in, the front desk collects vision plan benefits and routes the visit through VSP. The doctor diagnoses dry eye syndrome and bills the exam to vision.
The problem:
The visit was medical in nature—and vision plans like VSP typically only cover routine wellness exams. Because the doctor submitted a medical diagnosis, VSP denied the claim. When the team tried to rebill to the patient’s medical plan, they realized the timely filing window had already closed.
The result:
The practice wrote off the visit and follow-up services—over $280 in revenue lost.
The lesson:
The OD’s primary diagnosis drives the decision for a medical or routine visit. If a patient presents with a medical complaint, it should be billed to their medical insurance, even if they have a vision plan on file. It’s important to obtain both medical insurance and vision plan information at the time of service. A discussion should happen so that the patient is aware of how the claim will be billed if they have a medical diagnosis.
Example 2: Incorrect Copay
The scenario:
A returning patient has both medical and vision coverage. At check-in, the front desk assumes the copay is $10 based on their last routine exam, and collects it without verifying the reason for visit and the doctor’s primary diagnosis.
The problem:
The visit ended up being billed to medical (due to a diabetic retinopathy check), and the specialist copay was actually $60. The billing team had to research and bill the patient for the remaining balance of their patient responsibilities.
The result:
It took multiple follow-up calls and three months to collect the remaining $50. Some patients wouldn’t have paid at all.
The lesson:
The reason for the visit and the OD’s primary diagnosis determines how the claim will be billed. If the patient has a medical problem, the optometrist should discuss that during the exam so that there is no surprise when it is billed to the medical insurance and which copays will apply. Always verify medical insurance and vision plans prior to the appointment. Upon check-in, let the patient know what their medical insurance specialist copay is and their vision plan copay.
Example 3: The Out of Network Surprise
The scenario:
A new patient schedules a routine eye exam. The front desk verifies that they have Davis Vision coverage and collects the usual exam copay.
The problem:
The rendering provider was not credentialed with Davis Vision, a fact missed during the scheduling process. The claim was submitted anyway and denied due to being out of network. The patient was frustrated to learn they owed the full balance after the visit.
The result:
The patient left a negative review, declined to return, and the practice absorbed the cost to avoid further conflict.
The lesson:
Keep a credentialing list at the scheduling desk and front desk that can be referenced when checking to see if a provider is in network with a plan. Always check if the provider is in-network with the patient’s plan before the appointment, and clearly communicate any out-of-network costs in advance. Credentialing also needs to be maintained, so including the plan start date and the revalidation dates will help ensure you keep up with any deadlines. Put these dates on your office calendar with a 60 day advance notice as a reminder to take action.
The biggest takeaway here is that there is a lot of nuance in fully understanding patient benefits and then being able to communicate them well to patients. Repeated mistakes here can add up and hurt your reimbursements and AR aging over time. We’re here to help ensure your team is prepared to handle all benefit-related questions both with internal process and with patients. Schedule time to connect with us today.