Ben how do you handle these situations?
Thanks for your help.
I am not an EYE MED or Davis provider so I am not sure if the following response will help. I am a VSP provider which I assume is similar to those plans, other than a slightly higher reimbursement, so I will answer your question as though the patients had VSP.
1. EYE MED pt. comes in for REE & CLE . Pt. then tells you they have floaters. Do you bill both their medical insurance and EYE MED ?
As soon as the patient mentions to my staff (or me) that they are experiencing floaters, the exam ceases to be routine. I would inform the patient that before they can have a routine exam, they need to have the cause of the floaters ruled out. For that, I will need to perform a medical examination of their eyes which will not be covered by VSP. It will, however, be covered by their medical insurance which my office will gladly bill for them. I would then perform a dilated exam without refraction. If there is a PVD, or any retinal findings that need to be documented, I would do so and bill extended ophthalmoscopy as well. Obviously, if I find anything that needs to be treated, they would be referred, but in the case of a PVD, I would have them back for another eval in 3 weeks. Most of the time I go ahead and perform their VSP exam at that time. I could technically perform another medical exam without refraction and then have them back a third time for their routine exam, but I typically don't, although I would not question anyone that did.
2. Davis vision pt. comes in for REE. Pt. then tells you they have a Hx of retinal holes. You tell them that you will need their medical insurance. They tell you that dilation is covered by davis. What do you do? I have to go back to work.
This situation is a little different. In the case of an established patient that I have already documented the retinal holes (I will assume they are asymptomatic atrophic holes), I would go ahead and just perform the VSP exam. I would already have billed extended ophthalmoscopy and since there is no reason to repeat for this condition unless there is a change, I cannot bill for it again. Technically I could bill a medical exam every time and have them back for the routine exam, however, eventually the patient would grow tired of comming in twice a year for a stable condition such as this and I think they would leave the practice. If this is a new patient, I would tell them that I would prefer to have a baseline medical exam to verify that they have retinal holes. This is a medical exam that is not covered by VSP but is covered by their medical insurance. I would then do the same as in number 1, including the extended ophthalmoscopy. For asymptomatic atrophic retinal holes, I would not see them back except for their routine exam at which time I would refract, but not dilate (as long as it was shortly after the medical exam).
By performing extended ophthalmoscopy in both examples, I am going above and beyond what would be covered by a routine vision plan. If the patient insisted I only billed VSP, they would be charged for the additional procedure. I have never had someone do that, but I would assume that once told they would be on the hook for the additional procedures, they would have no problem with my office billing their medical insurance.
I hope that helps.
