Thanks to the COVID-19 pandemic, most of us have started spending even more time looking at flat screens of our smartphones, laptops, and computers. No matter how hard it may sound to believe, vision care service providers are currently in exponentially increasing demand thanks to a pandemic that is not connected to vision diseases at all. Optometrists and ophthalmologists have never stopped providing top-quality care to patients in this extraordinary time. Unfortunately, many of them have experienced large portions of underpayments thanks to a series of discrepancies and loopholes in the policies determined by commercial plans.
Before we proceed to the issues faced by optometrists and ophthalmologists nationwide, let us first uncover the difference between these two specialties. Both deal with eyes, but their spectrum of services is completely different.
Optometrists, O.D. (“optometry doctors”) are licensed to perform optometry, which primarily includes doing eye exams and vision tests, prescribing corrective lenses, and identifying certain eye abnormalities. They cannot perform surgery and medical services in general.
On the contrary, ophthalmologists are medical doctors who are allowed to practice medical treatment, perform surgeries, and to demonstrate a full spectrum of vision care services in general.
To sum up, while detection & prevention are key responsibilities of an optometrist, the actual treatment is a primary responsibility of an ophthalmologist. While the first specialty mostly performs eye exams to discover abnormalities, the second one focuses on treating such abnormalities.
Consequently, most commercial payers separate optometry coverage from that for ophthalmology services. Some patients may have their eye exams covered by their plans, while others do not. Meanwhile, other patients may have an active coverage for vision treatment, but their benefit plan will undoubtedly deny payment for eye exams.
Therefore, it is critical to properly check your patient’s eligibility prior to rendering a service.
Some insurance payers, like EmblemHealth, determine a list of services and conditions that are considered optometry (or “routine vision”) or ophthalmology. In the case of this particular payer, optometry services are not covered by EmblemHealth regardless of a patient’s benefit plan. Instead, eye exams and lenses are payable by a third-party entity – Eyemed, for which a separate enrollment is needed. A full list of EmblemHealth’s routine vision services can be obtained from the link below. Other payers apply a similar list of CPT and ICD-10 codes that are either covered or not.