How does vision insurance work?

[tjholmes]

Advertisement - Members don't see this ad

sorry im a student so this may seem basic to you guys.

Lets say my exam fee for an eye exam is $70.

for example if a pt has a vision plan like eyemed or vsp or something and they use that for the exam, so the way i understand it is that i would get reimbursed some of my normal exam fee (like $40) by the insurance provider for the exam.

what about the other 30. can i charge the pt for the rest or are they completely not expected to pay because of their insurance.

and how does a copay come into this.

basically what im asking is do i only make my full fees on pts with no insurance.

im trying to figure all this stuff out before i actually get out there. thanks.

 

[KHE]

sorry im a student so this may seem basic to you guys.

Lets say my exam fee for an eye exam is $70.

for example if a pt has a vision plan like eyemed or vsp or something and they use that for the exam, so the way i understand it is that i would get reimbursed some of my normal exam fee (like $40) by the insurance provider for the exam.

what about the other 30. can i charge the pt for the rest or are they completely not expected to pay because of their insurance.

and how does a copay come into this.

basically what im asking is do i only make my full fees on pts with no insurance.

im trying to figure all this stuff out before i actually get out there. thanks.

That's how it works with any benefit plan. As a participating provider, you agree to accept the contracted rate or your U&C, whichever is lower as payment in full for the services rendered. You can not balance bill the patient.

 

[optsuker]

Technically, it's not insurance at all, just a prepaid benefit program.
It covers 1 specific thing, 1 time per year. The plans make money by hoping enough people don't utilize it even though it's been paid for (usually by your employer).
The co-pay is a way to make you share part of the cost. A zero co-pay plan will cost your boss more.

Like Ken said, you agree to accept less in return for being listed as a panel provider.
Only private pay patients or plans that have an allowance greater than your normal fee will result in full payment.

Terms to be aware of:
Usual & Customary (U&C): Your normal fee for a procedure. Best to set this slightly higher than the best paying insurance plan, or you'll leave money on the table (ie: if plan allows $75 and your U&C is $70, they're only going to pay you $70 (and you can't charge different amounts based on the patient's insurance)).
Panel Provider (also Network Provider): You've agreed with the carrier/plan to accept a specific amount as payment in full. You'll be included in a list of providers the company recommends to their customers. (Many patients will never choose someone who isn't on the list).
Fee Schedule: List of all procedures and what the carrier is willing to pay for each one. You must ask to see this list prior to signing up to be a provider.
Out of Network: You're not listed as a panel provider. Patients can still come see you, but must pay your U&C fee themselves and get reimbursed by their insurance/vision plan. This is the route many OD's go if they feel the fee schedule is too low (the case with a lot of low-ball vision plans). Some plans don't allow this, but I've had great luck going this route over the years. Example: Patient pays my U&C of $120 to me, files OON claim form & gets reimbursed $75.
Co-Pay: Patient's share of their benefit. Can be a set dollar amount or a percentage. Big thing to note is that in most cases, the co-pay IS NOT in addition to the allowed fee schedule amount (ie: Allowance is $75 with a $20 co-pay. You're going to get $55 from the carrier and $20 from the patient, $75 total, NOT $75 + $20.

 

[tjholmes]

thanks for that info optsuker. pretty much answered all my questions.

 

[dantt]

The plans make money by hoping enough people don't utilize it even though it's been paid for (usually by your employer).

Actually, the plans make money because they own everything. The vision insurance, the optometrists, the optical shop, and the manufacturer. No joke.

 

[tjholmes]

How much do vision plans typically reimburse for a cl exam (exam and fitting).

 

[optsuker]

How much do vision plans typically reimburse for a cl exam (exam and fitting).

Too broad to answer: $0-?? & it may even vary by what state you live in.
The worst plans pay nothing & expect you to provide the service at no extra charge.

The biggest (VSP) pays a set fee for the exam (varies by state) and has a CL allowance that covers the CL eval & materials.
They require a 15% discount off your U&C CL eval fee and let you charge your U&C fee for the CL's themselves.
Example: Patient has VSP with $150 CL allowance.
Pt gets exam & year supply of Oasys
Exam (92014 or S0621): $125 CL Eval: $50 8 MPK Cl's: $288
VSP pays: contract amt less co-pay: $80. CL Eval-15%: $42.50 remainder of allowance: $107.50
Patient pays: Co-Pay: $20 balance of CL charge: $180.50