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Coordination of Benefits: Why It Needs to Be Part of Your Office Strategy

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August 31, 2023

The world of medical insurance and managed vision care plan benefits can often be confusing, both for patients and for the practice. Having a clear understanding of how to properly identify and use a patient’s full benefit structure can often help reduce out-of-pocket costs to the patient and simultaneously help the practice.

Coordination of benefits occurs when a patient has more than one form of coverage for procedures provided on a specific date. Processing the claims to the specific carrier, when multiple carriers/coverage exist, is when coordination of benefits comes into play. It is important to have a clear understanding of why the patient presented to the office, who is the primary carrier responsible, and who the secondary carrier is and their responsibilities.

How to Determine Who to Bill
Insurance laws, provider agreements, and carrier policies determine the order of policy coordination. If a patient only has a single plan, then responsibility for covered services falls solely to that plan. However, if a patient has more than one policy in place then the process of coordination of benefits can ensure that the patient receives their full allowed coverage for covered services from each responsible carrier, if they elect to do so. Additionally, it helps prevent benefits from duplication.

First and foremost, a patient’s chief complaint must drive the reason for the visit, which will then determine who gets the bill. If it is a refractive complaint or preventive-based comprehensive exam (diagnosis of myopia, presbyopia, etc.), then the managed vision care plan should receive the bill for the encounter. If it is a medical complaint that is the reason for the visit (diagnosis of diabetic retinopathy, dry eyes, allergic conjunctivitis, etc.), the medical insurance should get the bill for the encounter. It is appropriate that the medical insurance be used if the patient has any eye health problem or systemic health problem with ocular complications.

Here’s a simple example. An established patient presents to the office for a six-month follow-up exam related to macular degeneration. They have both medical insurance and a managed vision care plan for which you are a contract provider for both. During the case history, the patient expresses a desire to get new glasses. You perform the components of your medically necessary physical examination on the patient that would be commensurate with their presentation of macular degeneration. Based upon the patient’s desire for new glasses, you also perform a refraction that yields a spectacle prescription. How can coordination of benefits help the patient reduce their out of pocket costs and provide them with appropriate utilization of their benefits?

How to Code and Bill Both Insurance Carriers
In this circumstance, the patient’s reason for the visit was based on your medical record, and the visit was clearly medical in nature. The primary carrier responsible for the visit would be the medical carrier. A refraction was also performed based upon the patient’s request, but as we know, a refraction is not allowed to be billed singly to a managed vision care plan. So how can we get them to cover the refraction so the patient doesn’t have to pay the out-of-pocket cost, and you don’t have to write it off as so many of our colleagues do?

First, bill both the office visit and the refraction to the medical carrier. Please make sure that the appropriate diagnosis is mapped to each procedure. Since the medical carrier will not cover the refraction with a refractive diagnosis, it will get rejected. In most cases, you will create a paper claim for and bill the refraction to the managed vision care provider. Generally, you must also attach a copy of the EOB from the medical plan showing the denial of services. The managed vision care plan will then cover that cost.

Another common circumstance is when a patient has three insurance plans, one medical, one managed vision care plan through their employer, and a second set of benefits through their spouse’s provider. If done properly, these benefits can be coordinated, and the patient may qualify from more services. Each managed vision care plan has a very specific process for this, and it must be followed correctly. Not following the process correctly can certainly have ramifications in an audit.

For example, here is a link to VSP’s process for a patient who has two VSP plans, one of their own, and one with coverage from their spouse.

Coordination of benefits can be a wonderful tool to use to ensure that the patient is getting full benefits from their insurance coverage. Since each carrier has its own process for coordinating these benefits, it is important that you become familiar with the process for each carrier and keep current with any changes in policy as they occur. Doing so can provide a better patient experience, reduce their out-of-pocket costs, and help to ensure that you are getting paid to the fullest extent allowed within the policy constraints.


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