Billing for Medical Eye Services

While Vision Service Plan (VSP) and others reimburse optometrists for primary eye care services for many of its members, it may not be the case for full service health plans, such as Blue Cross and Health Net. Although many preferred provider organization (PPO) health plans will allow doctors of optometry to bill for medical eye care services, you should contact the plan to verify that these services are payable to optometrists prior to rendering services.

In contrast, health maintenance organization (HMO) health plans do not generally reimburse optometrists for medical eye care services. The advance of optometric scope of practice in California has outpaced adjustments by many HMO health plans to include optometrists as panel members. As one of its top priorities, COA continues to work towards gaining access to health plans for California doctors of optometry. Keeping optometry’s position and leverage strong are paramount reasons to maintain your membership and support of COA.

Plans supported with taxpayer funding, i.e., “publicly supported,” including Medicare and Medi-Cal fee-for-service, allow doctors of optometry to provide medical eye care services, such as foreign body removal or treatment of eye disease, etc. California law allows a Medi-Cal patient the freedom to choose to receive medical eye care services from a doctor of optometry practicing within the scope of their license (see Business & Professions Code, Article 8, Section 690).

In many parts of the state, however, Medi-Cal forgoes the fee-for-service model and contracts with private managed care plans to provide services. These managed care plans frequently contract with vision plans, such as VSP, to administer the vision care component of their benefits. Although VSP supports the enforcement of current law allowing patients with publicly supported vision coverage to select an optometrist for any service within an optometrist’s scope of practice, many Medi-Cal managed care plans that contract with VSP and other vision plans in the state only allow optometrists to provide basic vision care services, such as a comprehensive eye exam, while requiring the patient to obtain a referral from a primary care practitioner for medical eye care procedures.

More recently, California has rolled out a seven county pilot project where Californians who are eligible for both the Medicare and Medi-Cal programs (dual eligible) will be passively enrolled into a managed care plan. Counties impacted by this pilot project, which is formally named Cal MediConnect, include Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo and Santa Clara. This means that if you have a patient who is dually eligible and wants to remain in fee-for-service Medicare, he or she will have to actively choose to do so. If an enrollee does not select a plan, or does not opt out of Cal MediConnect, he or she will automatically be assigned to a plan. For more information, go to www.calduals.org.

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