Conflicting Insurance Providers

[Glados]

It's complicated. My hubby and I are stuck in the middle of an insurance billing dispute with our eye doctor's office. We have both medical insurance and a vision service plan. Both plans cover comprehensive eye exams. Medical covers treatments for medical issues such as glaucoma. The VSP covers glasses. Medical only allows one eye exam every two years. VSP allows one every 12 months.

The doctor is getting snippy with us about not coming in once a year. They have been billing our medical for the eye exam even though the VSP will cover it. Medical will not cover the exam until two years has passed. I spoke to the insurance billing person in the office and was promised that they will bill the VSP. They did not. The VSP is more than willing to pay and actually finds it strange that they bill them for glasses but never a visit.

I do not understand. They want us to come in once a year. We have insurance that will pay. They are legally allowed to bill said insurance. They refuse to bill the VSP and then give us grief when we refuse to come in for an out-of-pocket exam because they never bill the VSP.

[Andara Bledin]

I'm willing to bet that the medical coverage pays them more per visit than the vision plan and that's why they're so stuck on billing them.

You should probably pull the medical coverage information from the site so that they only have the vision option unless something comes up that won't be covered.

^-.-^

[Glados]

That's the issue with the medical. We have to provide the information at the beginning of the visit because if an unknown medical issue is discovered during the routine check it has to be billed to medical. The reason for this is to ensure that any additional tests that may be required for the medical diagnosis are also covered.

[Andara Bledin]

Ah. That makes sense.

It's a shame your doctor's office staff is too stupid to bill the correct insurance. Next time your doctor calls to badger you into coming in, you should blame your lack of visit on his staff and see what he says to that.

^-.-^

[HYHYBT]

Stupid question, I know... but what do they say when you ask them *why* they continually bill the wrong insurance?

[JuniorMintz]

I work for an OD and we are providers for VSP. Am I reading your question right and your OD's office is billing your major medical insurance provider for your routine eye care as if it were your primary vision coverage?

Also, are they strictly an optometrists office, or do they have ophthalmologists on site as well? The exams for optometry verses opthalmology are two different things and thus need to be billed to the correct insurance provider for payment. I.E. your optometrist should bill for your general eye health exam and eyeglass refraction, and your ophthalmologist for any visits in relation to your medical eye health (such as cataracts, glaucoma, keraticonis, retinal disease, etc.... the list goes on and on.)

Are you guys currently being treated by this office for a known medical issue beyond your routine exam where they would *have* to bill your medical insurance? If not, I'm *extremely* curious as to why they refuse to bill VSP for your yearly routine eye exam, especially since VSP is by far the easiest vision provider to deal with when it comes to paying out on their claims. (I'm not saying they're perfect, after all they ARE an insurance company... but compared to all other vision plans, they *are* the lesser evil).

My suggestion to you would be to contact the office again, and in this order. You may be on the phone for a while, so I suggest getting comfy and going potty beforehand.

1. Billing Head/Supervisor (do you know if you spoke to the main person in charge of billing earlier? Depending on the size of the practice, some offices have more than one person that deal with filing claims.)

2. Office Manager

3. Practice Owner -This person *should* be a doctor, hopefully the same doctor you see for your exams. (Side note: you mentioned that your doctor got "snippy" regarding the frequency of your visits. While there's no excuse for snippiness, it's possible your doctor may not be aware of the problem with his billing staff and thus thinks you're just being non-compliant in your visits. Doctors HATE non compliance, which may explain the crummy attitude. Never be afraid to discuss your concerns with staff with the doctors themselves!)

4. VSP customer service- The patient's number is 1.800.877.7195, according to their website. Request someone that works specifically in claims and tell them your concerns about your current office. With any luck, they will contact your OD's office directly and sort it out for you then.

Unless this office is honestly and truly stupid, they will remedy the issue with their billing practices long before you have to call VSP on them. No smart practice wants to do anything that may trigger an audit of their records. It's possible that the issues you've been having are due to error and not malice-still, if they are continually filing claims incorrectly, that's a BIG no no. (Trust me on this- I used to work for a practice that was kicked off the VSP panel for more than a year after failing an audit. Seeing as VSP paid close to 80 percent of their insurance claims, that was a HUGE loss of income!)

If this office is gracious about it and works quickly to fix the problem, great. If not, I'd recommend getting out of their ASAP and finding another private practice OD on your provider list. Please let me know how this all turns out, and best of luck!

[Glados]

Stupid question, I know... but what do they say when you ask them *why* they continually bill the wrong insurance?

They don't. They tell me that they bill the VSP unless a medical concern comes up. A medical issue has never come up. Then they bill the medical anyway but keep telling me that they are going to bill the VSP.

As for the type of doctor. They are listed as an optometrist office and we go there only for glasses. We have never had a medical complaint or had a medical concern come up during an exam with them. I do have Dwayne's syndrome but that is not treated or looked at as separate during an exam. They are able to work on medical conditions as well so I assume that at least one doctor is an ophthalmologist.

The exams consist of a regular screening and vision test. We get new glasses ordered and leave. Thank you for the advice. I will call them again and try to find out more. I suspect that they would bill the VSP if they knew that medical was used up but that is just not a risk that I want to take. If they fail to and we get a bill that is OOP we will have a big bill.

[blas87]

That's just sad. I've never had a problem with VSP before, in the few years I've had them.

The only thing I don't like is we have to pay a co-pay now, versus an entirely free exam every year, but that's not really that big of a deal.