Frequently Asked Eye Care Questions
Some insurance do require a referral from your primary care office or a prior authorization to be presented in order for services to be covered. These requirements should be explained in your coverage handbook, on the insurance carrier’s website or by calling the customer service number on the card. It is the patient’s responsibility to obtain any needed referral or authorization prior to arriving for their appointment or be prepared to cover all service charges.
Some vision insurance plans will cover a refraction (see above) on the same date as an office visit for a medical condition (with the medical insurance covering the office visit).
It is the patient’s responsibility to determine whether their vision insurance plan allows the refraction to be billed separately on the same date as a medical eye examination. If the vision insurance will not pay for the refraction on the same day, then this service needs to be performed on a different day or the patient is responsible for payment for the vision examination component of the office visit. (NOTE: Community Eye Care and many BCBS plans do not allow medical and routine billing for the same visit)
No. If the reason for the visit was for a routine vision examination, the visit cannot be billed to medical insurance per federally accepted billing guidelines. Therefore either:
- the vision insurance is billed (if the patient has vision insurance and the doctors are participating providers in their vision insurance plan) or,
- the patient is responsible for the examination fees on the day of service
Subsequent office visits and testing (on a different day) for the purpose of addressing the medical condition that was discovered as part of the routine eye examination are billed to the medical insurance.
This depends on the reason for the visit.
Examinations for medical care, evaluation of an eye complaint or to follow an existing medical condition are billed to the patient’s medical insurance plan.
Examinations for the purpose of checking vision, screening for disease, or updating eyeglasses or contact lenses are billed to the patient's vision insurance plan, if the doctors participate in that plan. Many vision plans will not allow coordination of benefits (billing of both plans), please verify your coverage with your carrier before your appointment
A refraction is the part of the office visit that determines the eyeglass prescription. Many times this involves the comparison question “which choice is clearer, choice one or choice two?” as different lens combinations are presented to the patient.
Medicare does not consider a refraction to be a “medically necessary” service, and therefore Medicare will not pay for this part of the examination. Some secondary or vision insurance plans, however, will cover this service.
It is important to remember that the patient’s insurance coverage is an agreement between the patient and their insurance company; NOT between the insurance company and the doctor.
Remember, insurance “coverage” does not necessarily mean insurance “payment”. Many health plans have required copayments and deductibles that must be met before they pay anything towards the patient’s bill.
In general, it is best for patients with commercial insurance (whether primary or secondary) to check with their insurance carriers (calling the numbers printed on the back of their insurance cards) BEFORE their office visit to:
- determine if they have vision benefits (and what those benefits are)
- determine if our doctors are participating providers in their plan
- determine whether or not refractions (determination of eyeglass prescriptions) are covered
Medicare does not pay for routine vision exams or refractions. Medicare beneficiaries may choose to have a routine or annual eye examinations performed, but the patient is responsible for full payment for these examinations on the day of service.
Some Medicare beneficiaries may have “vision benefits” that cover routine eye examinations through their secondary or supplementary insurance.
Insurance coverage often changes from year to year. However, it is the patient’s responsibility to know what their insurance plans cover and what they do not.
Insurance companies define a “routine” or “annual” vision examination as an office visit for the purpose of checking vision, screening for disease, and/or updating eyeglass or contact lens prescriptions.
The difference between routine vision examinations and medical eye examinations can be confusing and difficult to understand. There are, however, important differences between these two types of examinations and these differences determine how the office visit will be billed. Please read additional questions below.
Yes, as of June 2012 we are accepting Community Eye Care Plans. Please speak with our staff at your next appointment with any additional questions.
Any abnormal phenomena or changes in your vision can indicate a variety of possible problems. The key to preserving vision in the face of most eye diseases is early treatment. Thus it is important to consult an eye doctor if you notice anything unusual or any change in your vision. It could be a serious problem, or it could be inconsequential, but the peace of mind and the possibility of catching a serious problem early are certainly worth it.
Many serious eye diseases often have little or no symptoms until they are well developed. The only way to diagnose a problem early in such a case is to schedule periodic eye exams. This is the best way to preserve the clearest vision possible for life.
Ideally children should be seen by age one to make sure that everything is developing correctly, around age three when they can start to identify pictures and as the enter school to ensure that the best vision possible.
Children may need glasses for several reasons—some of which are different than for adults. Because a child’s vision system is growing and developing, especially during the first 5-6 years of life, glasses may play an important role in insuring normal vision development.
Eye exams are recommended periodically, with the interval differing for various age groups.
In the first three years of infancy, a child should have vision checked along with normal pediatric checkups. Between the ages of three and six (the most crucial period of eye development) an eye exam should be scheduled every year or two. After that period, until adulthood, exams should be scheduled as necessary. During the twenties, healthy patients should have at least one exam. During the thirties healthy patients should have at least two exams. In the forties, fifties, and early sixties, one should schedule an exam every couple of years. For seniors, an exam every year or two is recommended.
In addition to these basic guidelines, people with a family history of eye problems, those monitoring a diagnosed eye disease, or those with certain high risk diseases such as diabetes, it is recommended that exams should be performed at least once a year. Regular eye exams are the best way to keep you seeing your world clearly.
A large pupil allows the eye doctor to examine the inside of the eye in order to diagnose and treat eye diseases. Also, relaxing the focusing muscles of the eye allows for a more accurate measurement of refractive error (need for glasses) in children. Finally, dilating eye drops are sometimes used to treat eye diseases, such as amblyopia and inflammation.
If you are being seen for a complete exam, please prepare to be dilated. Your near vision may be blurry afterwards and most patients are light sensitive. In some instances distance vision may be fuzzy. We will provide temporary sunglasses but if you are wary of driving, please bring someone with you.
Appointment times vary depending on the type of care you are receiving and testing that may be involved.
For routine eye exams, patients should allow 1-1 1/2 hours and be prepared for dilation. New patients should allow additional time. Medical eye exams (diabetic, macular degeneration, etc) can take up to two hours. Patients being seen in a specialty clinic (for eye muscle disorder or double vision) should allow up to 4 hours.