UNDERSTANDING VISION EXAMS AND MEDICAL EYE EXAMS
We often have patients that have both vision and medical insurance. They are very different in terms of the services they cover and it is important for our patients to understand these differences.
Vision exams are designed to cover determining a prescription for glasses and to cover a routine evaluation of the health of the eyes in a healthy person that has no particular problems or symptoms. Essentially a routine vision examination checks for, but finds no medical problems. Since there are no medical problems, there is no discussion of problems or follow-up needed. Vision exams do not cover ANY medical testing, diagnosis, consultation or treatment. Vision exams cover ONLY routine eye exams for purchasing glasses or fitting and purchasing contact lenses. Some examples of vision problems are nearsightedness, farsightedness, astigmatism and presbyopia.
Medical eye exams are designed for when you have a medical problem that affects your eyes. Some examples of medical eye problems are: cataracts, eye infection/red eyes, floaters/flashes, eyelid styes, drooping lids, dry eyes/allergies, glaucoma suspect or treatment, loss of vision caused by a medical condition of the eye, any prior history of eye surgery, disease or injury, macular degeneration, diabetes, hypertension, high risk med use such as plaquenil or tamoxifen, etc. to name just a few.
If there is a MEDICAL diagnosis, we are required to submit the examination to the MEDICAL insurance. The copays and deductibles for the medical insurance will apply. A vision exam does NOT cover these kinds of problems. Also, a medical eye exam does not include the refraction, per insurance rules.
The fees for an exam that is medical in nature are set by following the Medicare insurance fee schedule for a medical eye exam and these fees are significantly higher than for a vision exam due to increased complexity in diagnosis and medical management and treatment of medical eye issues. Vision exams do not include or involve ANY medical diagnosis/testing or medical management/treatment or consultation and so are priced lower.
Our office does not make these rules, they are made by the insurance companies themselves, and we must comply with them. There is often no way to know prior to your exam what type of exam you will need or which type of insurance will be the right one to file your claim with. Our doctors will determine the appropriate type of exam and plan (medical or vision) to file your claim, based on the results of your exam. If we accept your vision or medical insurance we will file the claim for you. In the event we do not accept your insurance we will provide you with an itemized receipt that you may submit to your insurance for reimbursement.
Although our staff members are very knowledgeable about insurance plans, remember that it is not the doctor’s or staff’s responsibility to know the details of your individual plan. It is to your benefit to be aware of possible deductibles and co-pays or co-insurance that are part of your plan and it is your responsibility to pay these. If you have any questions, please let us know.