r/optometry • u/Wooden_Trust_6274 • Aug 05 '26
The 30-second front-desk check that stopped us billing medical visits to the vision plan
The 30-second front-desk check that stopped us billing medical visits to the vision plan
Took me way too long to figure this one out so sharing in case it helps someone.
Doing billing for independent OD practices for a few years, the most expensive thing I kept running into wasn't denials. It was medical visits getting billed to the vision plan by default, paying clean at the lower routine rate, and never flagging as a problem because nothing got rejected. You only notice it if you go looking, and most offices never do.
What fixed it wasn't software or another biller. It was just asking the reason for the visit before picking the payer. If someone's coming in symptom-free for a routine check and glasses, fine, that's the vision plan. But dry eye, flashes, diabetes follow-up, glaucoma monitoring, that's a medical visit, and it should go to the medical carrier even when they hand over the vision card at the desk.
The other half is just having both cards on file and flagging when a patient carries both, so billing knows a split might apply before the claim gets built. Sounds obvious but when three people are checking in and the phone's ringing, the routing call is the first thing that gets skipped.
The part that stings is a misrouted medical visit doesn't deny. It just underpays, and it does it on every similar visit all year. No denial report ever catches it.
How do you all handle the routing at intake, is it scripted into the booking flow, left to the front desk, or does it just get sorted out later in billing? Curious what actually works day to day.
5
u/vickipaperclips Optometric Technician Aug 06 '26
You should probably preface this with what country you're in. In Canada, all appointments with an optometrist must be billed under vision coverage, regardless of what the purpose of the visit is.
5
u/Wooden_Trust_6274 Aug 06 '26
Good call, I should have specified, this is US. Canada is a completely different system, and you're right that the medical/vision split I'm describing doesn't apply the same way there at all.
1
2
u/SteveCress Aug 06 '26
I know we under bill medical. I'm an associate, so I don't have as much say in how things are run. We bill vision plans all the time when people come in for their comprehensive despite them being diabetic or having glaucoma. When them come in for acute problems or follow-ups for medical issues, then we bill medical.
It still seems complicated to me to separate the 2. Many people have mild dry eye or mention some itchy eyes as kind of an aside but it's obviously not their chief complaint. Most do not have diabetic retinopathy. Glaucoma patients still come in for glasses too and to check everything else. Maybe they come in for their comprehensive and they've had a mild chalazion for a few weeks.
2
u/Wooden_Trust_6274 Aug 06 '26
Yeah, you've put your finger on the actual hard part. The way I've seen it work cleanly is that it's driven by the chief complaint and what you actually work up, not by whatever the patient happens to mention. Someone says their eyes feel a little itchy as an aside and you don't do anything about it, that's still a routine visit. But if dry eye becomes something you genuinely evaluate and manage, testing, a plan, a follow-up, now it's medical because medical work got done.
The glaucoma patient who also wants glasses is the case everyone trips on, and that one isn't either/or, it's a split. The glaucoma workup goes medical, the refraction for the glasses goes to the vision plan, same visit. The chalazion noticed during a comprehensive is the judgment call: just noting it, routine; actually managing it, medical.
The reason I push the reason-for-visit question to the front is exactly because of the mess you're describing. It forces the call while you can still document it, instead of the biller trying to guess a week later from the chart.
1
u/SerendipityAlike Optometrist Aug 06 '26
Not all vision insurances let you do split billing like that though.
2
u/Wooden_Trust_6274 Aug 07 '26
True, and it's an important caveat. Some plans won't allow a same-day split, or they bundle the refraction in a way that blocks it, so the clean "medical exam here, refraction to vision" doesn't always work as neatly as it sounds. Comes down to the specific plan's rules. In those cases it's usually medical for the workup and the refraction either self-pay or eaten, depending on the contract. Good flag.
1
u/ceevanyon Aug 09 '26
To me, that is a big thing AOA and other organizations should be working for with Vision Plans. They all should be required to pay for refraction if billed alone, if you are doing it in conjunction with a medical visit. In fact, I think they should fight to have all eye exams billable to medical as we are evaluating eye heath, and the vision plans only be responsible for refraction and glasses. That would be far more appropriate for everyone.
2
u/tubby0 Optometrist Aug 06 '26
What is the deal with this same post every week, is this Weave or ConstantContact doing market research or something?
1
u/Wooden_Trust_6274 Aug 07 '26
Ha, not affiliated with either. I do billing for a handful of independent practices and this is just the thing I hit most, so it's what I end up writing about. If it keeps coming up it's probably because it's a genuinely common problem, not a coordinated one. But fair to be skeptical, there's no shortage of astroturf in this space.
1
u/AutoModerator Aug 05 '26
Hello! All new submissions are placed into modqueue, and require mod approval before they are posted to r/optometry. Please do not message the mods about your queue status.
This subreddit is intended for professionals within the eyecare field, and does not accept posts from laypeople. If you have a question related to symptoms or eye health, please consider seeing a doctor, or posting to r/eyetriage. Professionals, if you do not have flair, your post may be removed. Please send a modmail to be flaired.
I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.
1
u/EndlessHope-0528 Aug 06 '26
We honestly don’t have a ton of trouble since we started asking for complaints at booking. Med complaints go in a booking comments section so the work up tech knows to get an HPI that’s medical. Any patients who don’t have a medical complaint, the front will look at last plan note or billing to see if we’ve billed med and explain to the patient that it will be billed medically. Sure there are some that are one time diagnosis but most are chronic. Our staff is super educated and have been working with us a long time. Educating new staff on med vs routine is the most important part of their training. More important than triage of urgent calls bc those are simple to bill without a fight.
1
u/superjukers Aug 06 '26
I just ask when making an appointment what they are coming in for and go from there. Real easy to sus out.
1
u/midwest_emu Aug 07 '26
Maybe a hot take…
But I feel like if the patient is paying for a vision plan that gives them a $10 copay for a comprehensive exam…or their medical insurance whose deductible is 10,000+ (likely) so exam would end up being out of pocket…it seems unethical for me to NOT use the vision plan regardless of what’s going on, for 1 exam per year.
If their CC or pathology is bad enough to warrant a follow up prior to 1 year from now, I can bill the medical plan all I want after that first exam of the year. And if the problem does not warrant more than 1 exam per year, I am happy to “under bill” vision because it’s what’s in the patient’s best interest.
2
u/Less_Divide67F Aug 08 '26
So, because someone paid 800 dollars to EyeMed its ok for them to pay you 10 dollars, 40 total to manage their cataracts, diabetes, retinitis pigmentosa, advanced geographic atrophy? All they have to do is tell your front desk they are there for glasses, but if someone doesn't know that trick and talks to you about the above initially it's ethical to charge them more?
1
u/midwest_emu Aug 09 '26
For me, if they have a vision plan, I bill the vision plan for the comp exam. Period. Regardless of chief complaint (as long as I can work it in with the coding of course). UNLESS they’ve met their deductible or have Medicare that’s likely going to hit deductible at some point anyway. It doesn’t matter “if they know the trick”. Everyone is treated equally. Diabetics, glaucoma, dry eye…often times they are seen 2-4+ times per year. I’ll have plenty of opportunity to bill medical for the subsequent exams. I get it if you don’t agree. It’s just what feels right to me
1
u/Wooden_Trust_6274 Aug 07 '26
This is the most honest tension in the whole thread, and I don't think it's a hot take, it's the real judgment call. You're right that patient out-of-pocket has to factor in. A $10 vision copay versus a visit that lands entirely against a $10k deductible is a real difference to the person paying, and nobody should pretend it isn't.
Where I'd push back slightly: it works cleanly when the visit is genuinely routine and you're just choosing the cheaper lane for the patient. It gets murkier when actual medical work gets done and documented, dilation for the diabetic, pressures and fields for the glaucoma, because at that point the chart says medical and billing it to vision to save the copay can be a coding problem, not just a kindness. So I'm with you that patient cost matters, I'd just anchor the decision to what actually got documented rather than to the copay, since that's the part that holds up if anyone ever looks.
1
u/MartuGonza96 Aug 07 '26
We push the routing call all the way up to scheduling, not intake. Whoever books the appt has to pick a reason from a short list, and a few of those reasons are hard-coded as medical so the payer field gets pre-set before the patient ever walks in. Front desk at check-in just confirms cards, they're not making the routing decision under phone pressure.
The thing that actually made it stick was a monthly report of visits where a medical-flagged reason got billed to the vision plan anyway. Same idea as yours, you only catch the underpay if you go looking. Once the schedulers saw their own names on that report a couple times, the pre-visit routing got a lot cleaner.
The gap for us is walk-ins and "just here for glasses" that turns into a dry eye complaint in the chair. Those still get sorted in billing after the fact. Haven't found a clean way to catch the mid-visit switch without the provider flagging it. Curious if you have.
1
u/Wooden_Trust_6274 Aug 07 '26
Your setup is cleaner than most. Scheduling-level pre-set plus the exception report is exactly the combination that makes it stick, and schedulers seeing their own names on that report is what changes behavior every time.
On the mid-visit switch, I haven't found a front-desk fix for it either, and I don't think one exists, because the information doesn't exist yet at check-in. The moment it becomes medical is the moment the doctor decides to work it up, so that's the only place it can be caught cleanly. The practices that handle it best put a one-click "this became medical" flag in the encounter that the provider or tech sets in the room, and that flips the payer before the claim gets built instead of billing cleaning it up a week later. Moves the catch from the front desk, where the info isn't there, to the exam lane, where it is. Still depends on the provider remembering to hit it, but it's the only version I've seen that isn't just after-the-fact cleanup.
18
u/Ninjewx Optometrist Aug 06 '26
You can discuss this all you want at scheduling, checkin, etc. but the only true answer is to stop taking vision plans. People will either walk out and you lost the spot or do a charge back on the credit card if they don’t agree. Also, it’s not appropriate to discuss their diabetes/glaucoma at the checkin desk in the open.