Billing Insurance For Vision Therapy: A Comprehensive Guide For Practitioners

Billing insurance for visual therapy can be a complicated process. Visual therapy is typically covered by major medical insurance rather than a vision insurance plan. The billing process depends on the patient's insurance plan, the type of treatment, and the length of the session. It is important to verify the patient's insurance coverage and understand their policy's specific requirements, such as pre-authorization or annual limits. The therapist or healthcare provider must select the appropriate Current Procedure Terminology (CPT) code for each treatment session, ensuring proper billing and prompt payment. In some cases, patients may need to seek reimbursement from the insurer, which can be a challenging process. To streamline billing and reimbursement, therapists can join an insurer's provider panel, allowing them to bill insurance directly and potentially increase their earning power by serving clients who depend on insurance coverage.

Understanding the difference between vision plans and medical insurance

Vision plans and medical insurance are both important, but they serve different purposes. The main factors differentiating the two are the type of eye exam and the reason for visiting an eye doctor.

Routine vs. Medical Eye Exams

Visits to an eye doctor are typically classified as either "routine" or "medical". A "routine" eye exam is often covered by vision insurance and includes vision tests, contact eye exams, eyeglass lenses, and frames. On the other hand, a "medical" eye exam is covered by medical insurance and is required for treating and resolving medical issues with your vision. These issues are considered medical as they need to be treated by a physician and may require medication.

Vision Insurance Coverage

Vision insurance provides coverage for routine eye care, including eye exams, corrective lenses, eyeglass frames, and contacts. It is important to note that vision insurance is typically used once a year and cannot be separated into examination and refraction. Vision insurance is ideal for individuals who require routine eye exams and corrective lenses in addition to preventive care.

Medical Insurance Coverage

Medical insurance, on the other hand, covers unexpected costs for eye injuries or diseases. It is used for situations where there is a medical sign, symptom, or ongoing care for a medical condition. Medical insurance is also used for eye surgeries, such as cataract or glaucoma treatment, and covers medically necessary procedures. It is important to note that medical insurance can be used multiple times a year, depending on medical necessity.

Knowing Your Coverage

It is essential to understand the coverage provided by your insurance plan. Both vision and medical insurance plans vary among insurance companies, so it is crucial to review your specific policy and contact your insurance provider for clarification. Additionally, be aware of possible deductibles and co-pays to avoid unexpected out-of-pocket expenses.

Knowing which CPT insurance billing codes are covered

When billing for vision therapy, it is important to know which CPT codes are covered by the patient's insurance policy. Vision therapy typically falls under medical policy rather than a vision policy. The following CPT codes are commonly used for billing an initial vision exam of 1-2 hours: 99203, 99204, and 92015. For assessing a patient's visual information processing during a 2-hour appointment, commonly used CPT codes include 96111, 96116, or 92060. Therapy sessions lasting up to an hour often use the code number 92065. For progress visits, codes 99213, 92060, 96111, and 96116 are commonly used.

It is important to note that different CPT codes have specific time ranges associated with them. For example, the CPT code 90832 is for a 30-minute psychotherapy session, while 90834 is for a 45-minute session. CPT codes also have modifiers, which are two numbers or letters added to a CPT code to define precise steps in a procedure. For instance, the -24 modifier is used when a doctor performs an office visit unrelated to a previous procedure during the global period.

In addition to CPT codes for office visits, there are also procedure codes that need to be considered. For example, bilateral procedures like fundus photos (92250) and threshold visual fields (92083) have one fee associated with them, regardless of whether the procedure is performed on one or both eyes. On the other hand, unilateral procedures like corneal foreign body removal (65222) allow a separate fee to be charged for each eye.

When selecting CPT codes for vision therapy, it is crucial to refer to the most recent CPT manual and billing guides to ensure accuracy and avoid claim denials.

Knowing the out-of-network deductible

When a doctor or healthcare provider is not part of your insurance plan's approved list, they are considered out-of-network. Out-of-network providers can charge you the full price for their services, which is typically much higher than the discounted rate offered by in-network providers. This means that you may have to pay the difference between the provider's bill and what your insurance plan covers.

Many health insurance plans have separate deductibles for out-of-network services, and these deductibles tend to be higher than in-network deductibles. For example, if your out-of-network deductible is $2500, you must pay for $2500 worth of services before your insurer starts contributing to the cost. Meeting this deductible can significantly reduce the cost of out-of-network services, as most plans only agree to cover these costs after the deductible has been met.

It's important to note that some plans do not offer any out-of-network benefits, and you may be responsible for the full cost of care received out-of-network, except in emergencies. Additionally, the amount you pay towards your out-of-network deductible may not always count towards your in-network deductible, and these may be considered separately by your insurance plan.

To lower your out-of-pocket expenses, it is generally advisable to use in-network providers whenever possible. However, if your insurance plan's network does not offer a wide range of providers or services, exploring out-of-network options may be necessary. In such cases, understanding the out-of-network deductible and coverage becomes even more crucial.

By familiarizing yourself with the out-of-network deductible and how your insurance plan works, you can make informed decisions about your healthcare choices and manage your expenses effectively.

Knowing the coinsurance payment

When billing insurance for vision therapy, it is crucial to understand the patient's insurance plan and what services are covered. Vision therapy is often considered a medical procedure and may be covered under a patient's medical insurance plan rather than their vision insurance plan. It is important to verify the patient's insurance coverage before providing treatment.

Some insurance companies may cover vision therapy, but it is important to check with the insurance provider to see if the patient's specific policy includes this coverage. Additionally, there may be an annual or lifetime limit on the coverage. It is also important to ask about pre-authorization requirements and reimbursement timelines.

When billing for vision therapy, specific CPT insurance billing codes are used. For initial vision exams, the codes 99203, 99204, and 92015 are commonly used. For assessing a patient's visual information processing, the codes 96111, 96116, or 92060 may be applicable. Therapy sessions lasting up to an hour often use the code 92065. For progress visits, codes such as 99213, 92060, 96111, and 96116 are commonly used.

It is important to note that insurance companies may have different requirements and guidelines for billing, so it is essential to review the patient's specific plan and understand the billing codes that will be covered. The patient's coinsurance payment will depend on the costs of the treatment and the percentage of costs they are responsible for under their insurance plan.

Knowing the reimbursement time

To ensure prompt reimbursement, it is essential to submit your claim within the insurer's specified timeframe. Deadlines for submitting claims vary among insurers, and it is your responsibility to adhere to these deadlines to avoid delays in reimbursement. For instance, Medicare and Medicaid typically require claims to be submitted within 365 calendar days from the date of service, while private insurers often set shorter deadlines, such as 90 days.

Therapists who work with multiple insurance companies must stay organised to meet the varying deadlines. A practical tip is to identify the shortest filing period among all the insurers and then file all claims within that period to avoid missing any deadlines.

Additionally, therapists must be reimbursed within 30 days of submitting their claims. However, coding errors or other issues may cause delays in reimbursement. Therefore, it is crucial to keep track of each bill sent out and follow up with the insurer if payment is not received within the expected timeframe.

To streamline the reimbursement process, it is beneficial to discuss insurance policies with your clients beforehand. Verify insurance coverage and reimbursement rates with new clients, and request that they notify you of any changes in their insurance providers. By being proactive, you can help your clients navigate the complexities of insurance reimbursement and reduce potential delays.

Frequently asked questions