Vision Plan or Medical Insurance?

Most people have medical insurance and/or a vision plan.  They are very different in terms of the services they cover and it is important for you to understand these differences.  All eye doctors in the U.S. are obligated to follow these laws and eye doctors are the only medical specialty that is governed by two different sets of third party reimbursement rules. In many cases there is no way to know prior to the examination which type of insurance will be applicable.

Vision Plan

A vision plan (e.g. VSP, Davis, Spectera, Superior) is designed to determine a prescription for glasses or contacts and pay for glasses and/or contacts.  It is not designed to pay for diagnosis or treatment of medical conditions.  Vision plans do allow for screenings of eye diseases if there are no signs, symptoms or complaints or previous history of problems.  However, if there are complaints, signs symptoms, previous eye disorder diagnosis, or physician recommended exam, then vision plans DO NOT cover the office visit.  Medical insurance would then be used for that type of office visit.

Medical Insurance

When the reason for the office visit is a medical condition such as diabetes, cataracts, dry eyes, allergic eyes, floaters, hypertension, retina disorders, glaucoma, blepharitis, conjunctivitis, red eyes, irritated eyes, eye pain, etc. or a complaint, sign or symptom related to a medical condition, we are required by law to file the exam/office visit charges to a patient's medical insurance (e.g. Blue Cross, United Health, Aetna, Tricare, etc.).  Additionally, if the office visit was recommended by a physician the office visit is billed to the medical insurance carrier.

By law, we cannot file the claim to your vision plan in those situations.

Collection and Fee Amounts

We (and all doctors) are required by law to collect your co-pay (we are classified as specialists for co-pay amount), co-insurance, deductible and fees for non-covered services and will do that at the time of your office visit.

The amount of our fee for covered services is dictated by the insurance company and we often don't know the exact amount until the claim is adjudicated by the insurance company.  Appropriate fee discounts will be included in the fees to arrive at the insurance "allowable charge".