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Could Retail Optical Benefit Your Practice?

Optician offering glasses to a patient.

As an ophthalmology or optometry professional, one of the best moves you can make to grow your practice is to incorporate a retail optical outlet as part of your operations. This move makes sense when you consider that one of the key factors that patients consider when choosing eye care is their health insurance.  

As a medical professional, a visit to your practice would be billed under their medical plan instead of their vision plan. However, if your patients require a basic examination or to purchase glasses, contacts, or other vision aids that you prescribe to them, the cost would be covered by their vision insurance.  

By incorporating a retail vision care component into your operation and understanding how optical billing and coding work, you can bill the patient’s vision insurance without falling foul of regulations. 

Retail optical services also provide your practice with a non-insurance-dependent stream of revenue, allowing you to weather economic shifts and declines in insurance reimbursements. 

Examine If an Optical Dispensary Is a Good Fit for Your Practice 

Suppose your ophthalmology practice is looking at adding a retail optical shop. In that case, one of the crucial questions you should ask yourself is if you can offer optical solutions that can compete with specialized optician shops. 

Although an attached optical shop can boost your vision care practice’s revenue, you need to know that if your optical clinic cannot spend sufficient resources to hire adequate staff or not put in the effort needed to make it a good investment, you could easily fail. 

Also, the cost of adding retail optical to your practice is relatively low compared to the potential earnings. 

Differentiating Medical and Vision Insurance 

Most people use some form of insurance to pay for their vision care, allowing your practice to bill their insurance plan to pay for retail optical services. However, is there a difference between vision insurance and medical insurance? It can be confusing and complicated because billing for ophthalmic services is often different from other medical billing types. 

Vision care may fall under a regular medical insurance plan or a plan designed exclusively for optometric care. It is illegal for a practice to bill both the vision insurance payor and medical plan payer for the same service offered to a patient. For this reason, the provider needs to understand the differences between both types of insurance clearly. As a provider, you usually choose to bill for vision care based on your patient’s main complaint. However, choosing between them is rarely straightforward. 

Vision insurance can pay for routine eye examinations and retail costs of prescription and replacement glasses and contacts. On the other hand, medical insurance caters to patients exhibiting medical symptoms or continued care for their medical conditions. Additionally, there are different limits to the number of times a patient can use the two coverage types per year. Most patients can only use their retail vision plans once a year, unlike medical programs that they can use more often since illnesses and medical issues are common. 

Suppose you want to maximize your team’s efficiency in billing your clients for medically needed glasses, contact lenses, or other vision care accessories. In that case, you need to read through the vision care insurance provider’s terms to know what they cover. Contact key insurance cover providers and have them walk you and your team through their information. You should also ensure that you get prior authorization when you prescribe glasses or contact lenses to avoid any billing surprises.

Test Your Billing Staff’s Billing Knowledge 

As an ophthalmology practice, you rely on your billing staff and administrators’ skills and knowledge to keep your office industry-compliant and help maximize your revenues from retail optical services. As such, some optical care practices prefer to hire admin staff with little to no experience in medical billing, expecting them to learn “on the job.” On the other hand, you could prefer to get someone on board with extensive industry knowledge needed to hit the ground running. 

Although hiring a so-called “veteran” to handle your business could be tempting, especially if you are new to retail billing, you might hire an employee who might introduce non-compliant ideas into your practice. If you want to be sure that your business is on safe ground and that your candidate maintains appropriate billing standards, you should ask them (and yourself) a few questions to test their knowledge: 

● What documentation do you need to code a consultation? 

● What’s the difference between a procedure and a diagnosis? 

● Does every payer handle code CPT code 99213 the same? 

● What differences exist between eye codes and the Evaluation and Management codes for clinic visits? 

● How do you code unilateral procedures? 

● Can you provide a full definition of CPT code 66982? 

● Do you understand bundling and upcoding? 

Becoming an expert in optometry coding and billing will take time and effort. To make your team’s job easier and put your patients at ease, you need to understand the difference between medical and routine plans, how deductibles affect your fees, and the applicable copays. 

Eyeglasses on a shelf at an optician shop.
Incorporating an optical shop into your eye health practice could provide another revenue stream. But keep in mind the resources this plan requires to be successful. 

Let ApexEDI Help Smooth Your Vision and Eye Care Billing Procedures 

Coding and billing for optometry services are often burdensome and complicated, but you must get it right. Manual billing and insurance claims can take a long time to process and are prone to mistakes. Some standard coding and billing issues like incorrect coding, under-billing, or over-charging could trigger severe consequences for your practice. These problems could lead to expensive fines and financial audits or more serious ramifications like fraud charges and criminal proceedings. 

I just wanted to let you know we are seeing payments and the turnaround time is AMAZING! Apex is allowing us to collect so much faster than before, and our over 60 days receivables are down by 23%.

Bethany Cassar, Complete Eye Health 

However, with Apex EDI, your practice can now complete billing processes that would typically take days in a few seconds. Apex has years of experience in processing patients’ insurance claims for optical care practices since 1995, helping doctors stop worrying about billing, so they can focus on their patients’ welfare.  

When you integrate the Apex EDI solution with your vision care software, faster claims processing means that you can provide better patient care and boost your earnings. Schedule a free demo of the Apex EDI claim processing solution today and learn more about how simple billing for vision care can be. 

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Apex EDI, Inc.
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Orem, Utah 84097
Support: (800) 840-9152
Sales: (801) 383-0388
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