In 2014, I wrote an article discussing whether or not to take insurance for vision therapy. I then updated it after a year and a half when I decided to open my own practice that was primarily going to be a specialty care practice focusing on vision therapy and rehabilitation. I am nearly 7 years in practice now, and want to highlight the things I have learned and what has changed after ‘being in it.’ Here is all of my advice from my experience, updated for 2022.
So you've decided to forge forward with vision therapy, you are excited, have a business plan ready to go and then comes your first big business decision: do I take insurance for vision therapy or not? This question was one that I mulled over for weeks (if not months) with myself and as many vision therapy doctors as I could get in touch with. I am in no way an expert on billing/coding, but what I can share with you is my experience with this question and how I came about my decision.
So let's get a few basics out of the way...
- With any service that you provide in your office, you have the decision to be on an insurance panel or not.
- You can still see patients that are not covered under insurance, but it will be an out-of-pocket expense to those patients.
- If these patients have “out-of-network” benefits, they can submit your exam to their insurance for reimbursement.
- Most doctors bill an office visit (92012) and an orthoptic training (92065) code for therapy.
- Some doctors offer ``Vision & Learning” sessions that address the perceptual aspects to vision. This is never covered by insurance as it is considered "educational."
- Other options include 97000 codes for rehabilitation (I am not familiar with these, but click here for a great article provided by COVD’s practice management series).
Now that we have those facts out of the way, let's talk about our options:
Option #1: Take insurance
This seems like the easiest option, right? You are most likely already on the big insurance panels for your primary care patients, so why not offer vision therapy as a service through these panels? In a perfect world, this would be the best option—your patient gets the service they need through their insurance and you get reimbursed for your services. Well, it is not that simple.
Insurance coverage is not straightforward: patients have high deductibles, large copays, and many services that are not covered. Each plan for each patient is different, which means you have to be the detective to determine if the insurance company will cover the service and the diagnosis code.
For every patient, it is recommended that you speak to the insurance company and determine prior to starting therapy whether the service is covered or not. This may take weeks, but you do not want to tell a parent that therapy is covered and then eight sessions to find out you are getting denial letters. When this happens you are left with two bad results—an angry parent that technically owes you money and a kid that has started therapy, but may not finish.
Don't get me wrong, taking insurance for vision therapy isn't all bad. Once you have figured out a system to see if vision therapy is covered or not, you will be better geared to deal with the parents and present all of the options to them. Taking insurance does allow you to see your primary care population without a problem.
In the beginning, while you are building up a reputation in the community, taking insurance helps tremendously in building your patient base. My advice is if you are going to accept insurance for therapy, don't get on EVERY panel. Some panels are known to pay more than others, but each region varies. I recommend using the COVD Mentorship Program to touch base with a doctor in your area to see if they have advice for which panels are worth dealing with.
As I stated earlier, some doctors break their therapy programs into "orthoptic" sessions and "vision and learning" sessions on an alternating basis. These vision and learning sessions address oculomotor activities, visual memory, spatial relations, laterality and directionality and other perceptual areas. In my experience, the perceptual portion is the key to unlocking a child's full visual potential (an article I wrote for the COVD blog describes all of these areas and why they are important).
With that said, these vision and learning sessions are not covered by insurance because they are deemed "educational." From the doctor's perspective this guarantees at least half of the vision therapy program will be paid for up front, which may offset the low reimbursements from the insurance companies.
Pros and cons of accepting insurance
- Build population base
- Offer services to many patients
- Able to see primary care
- Getting approval may take weeks
- Possible withdrawal of payment
Option #2: Don't take insurance
Now that I've gone through the battles of taking insurance, you're going to think well " taking no insurance is a no brainer." Well, again this option has its pros and cons as well.
Vision therapy is not cheap and unfortunately many people don't always have extra money to spare, no matter how valuable they think your service is. For example, a typical vision therapy program is say anywhere between 24-32 sessions. At $125/session, that is $3,000-$4,000 dollars, not including maintenance material and re-evaluations. Offering services such as Care Credit (a medical financing program) to patients does help to offset the blow a little bit.
On top of the large cost to patients out of pocket, how are you as the doctor going to offset the time you are not seeing patients? In the beginning, you are going to be building up your vision therapy, but probably not making a ton of money. Most optometric practices' bread and butter is primary care.
If you aren't on any insurance panels, will patients come in to see you and pay out of pocket?
These are all questions you have to ask yourself before jumping ship on insurance.
Each doctor's situation is different. If you are in a group practice, it might be easier to stay off insurance and just see those private pay patients. You can also work only when you have a vision therapy evaluation or therapy.
The pros are easy here: no hassle of dealing with insurances to determine if the service is covered; the price is what it is and your patients can decide what they want to do, the amount of money coming in from the business is straightforward, and you have a bigger commitment from your patients because they are actually paying for the service.
Pros and cons of not accepting insurance
- No dealing with insurance companies
- Straightforward reimbursements
- Increased patient commitment
- May lose patients that can’t afford therapy
- Can’t perform primary care services (unless private pay)
When I first presented my business plan to my boss, I pushed for him to keep me off of insurance panels. We decided on a trial period for me to not be on insurance panels—a small victory in my book.
Well . . . a month later I wasn't holding up my end of seeing enough primary care (our office does not have many private pay customers) and we had to find a middle ground. The agreement was that I would join certain panels (not all) that I knew reimbursed well enough for both primary care and vision therapy.
There were two catches to this agreement. One, my boss had to understand that we may lose money on some patients due to low reimbursements for the therapy. To offset this, we decided to run our therapy sessions while another doctor was seeing primary care. The second catch was that once I was booked up for evaluations 2 weeks in advance and needed to add times for vision therapy, I could start coming off certain panels.
Fast forward one year and a half, and I found myself faced with the very same decision, but this time it was not just vision therapy-related as I was opening up a brand new full-scope practice cold.
If you talk to some older docs, they'll tell you traditionally it is best to get on as many insurance panels as possible when opening a brand new optometry practice location to encourage as many people as you can through the door.
Unfortunately, insurance and reimbursements are just not what they used to be.
I am going to list my top three reasons why my partner and I chose to only participate with only THREE major medical insurances (Medicare, Blue Cross Blue Shield, & Aetna) and only ONE vision plan (EyeMed - primarily for contact lens benefits).
Consider minimizing insurance when . . . offering specialty care services
My practice offers full-scope optometric care, but our primary focus is on vision therapy and rehabilitation. For that reason, it made sense to limit the plans that we participated in because many insurance companies will not cover vision therapy services. We did not want patients to be confused by the fact that their routine exam was covered, but they would have to pay for therapy.
Here is a true story: a patient paid for therapy out of pocket because we did not participate with his insurance, but was told by three (THREE) different people at his insurance that he would be reimbursed because he had out-of-network benefits and the service was covered. Well, lo and behold, he submitted his claim and it was denied because the "service was actually not covered and those three people he spoke to were mistaken."
Yeah. Not a great story, and many VT doctors will tell you stories of getting verbal approval over the phone just to start therapy and then later receive denial letters for the service.
Any specialty care service such as orthokeratology, scleral lens fittings, or even some dry eye procedures are typically not covered by insurance. If you plan to set yourself apart in your community by offering these services, consider being selective about the insurances you take.
Consider minimizing insurance when . . . you don’t have an optical
As mentioned in a previous article, we decided to open our practice without an optical.
Because of this, we were not eligible for certain panels because we did not offer spectacle services in-house. EyeMed in particular allows its members to “split their benefits” meaning they can see one provider for their exams and then go elsewhere to purchase their spectacles. We do offer contact lens exams and ordering of contacts through us.
Consider minimizing insurance when . . . you want autonomy
I've worked in both retail and private practice (one took every insurance and another took very limited insurances) before opening my business.
My experience was in the practice settings that took almost all insurances, I was running from patient to patient, spending maybe 10-15 minutes with each one, oftentimes not getting a lunch and by the end of the day my head was spinning.
After all of that, the day's net profit was considerably out of proportion with the amount of work I had put in.
It felt like I was just working to be busy, but not to be profitable.
Take this example:
Exam cost for a new private pay patient: $125
Exam reimbursement from X insurance: $40
In the same amount of time I would spend with the private pay patient, I would have to see THREE of those low reimbursing insurance patients to make the same amount of money.
Would you rather see more patients, but not make any more money? I think I know the answer.
Ultimately, by taking the insurances that work for best for your office and eliminating the ones that are bogging things down, you will be able to spend a little more time with your patients, give them a higher level of care and receive appropriate payment for your service that is not always dictated by an insurance company.
Are you currently working in an office where you are on every insurance panel and seeing a lot of patients, but not really making the money you should?
If so, review which plans are costing you money or not worth the headache and start to drop them.
What insurance is worth taking for vision therapy?
Well, here we are almost 7 years into being a private practice owner and guess what? I still only take the insurances I listed above. We have added no-fault insurance, worker’s compensation and school insurance (if a child gets hurt at school) due to the fact that we have created and maintained a referral relationship with a concussion center that works with these insurances. I am going to highlight the ups and downs of all the insurances we take and our experience:
Aetna: Aetna is tricky in the sense that they will only cover the diagnosis of convergence insufficiency (H51.11) and for only 12 sessions per calendar year. Unfortunately, not every patient falls into this box and most patients need more than just 12 sessions. Some patients opt to pay out of pocket for their additional care.
Blue Cross Blue Shield (NY): Most BCBS plans cover vision therapy for any wide array of visual dysfunctions such as convergence insufficiency, convergence excess, accommodative issues, oculomotor dysfunctions, amblyopia and strabismus. They usually cover 21 sessions and then require prior authorization for any additional sessions that may be necessary. The patient is liable for their specialist copay every time they are seen.
As of late, we have run into some plans not covering therapy services, but we have created a system to call for confirmation prior to the patient starting therapy so there are no surprises (no assumptions here because we know what happens when we do that.)
Medicare: By far the easiest commercial insurance to work with when it comes to vision therapy. There doesn’t seem to be a limit to sessions or visual diagnosis. Again, we do not abuse the system and do the least amount of vision therapy sessions to garner the most amount of change within our patients.
The one caveat here is sometimes we do not participate with the patient’s secondary insurance which leaves about 20% for the patient to be responsible for (medicare covers 80%). We let the patients know ahead of time that this may be the case.
Most no-fault insurances will cover our services initially and then require the injured patient to attend an independent medical exam (IME) to determine if services are still warranted. We always communicate with the insurance company and submit all of our findings and reports to the IME doctors.
The one downside to taking this insurance is if the IME physician deems the patient ‘better’ they will cut off services almost immediately, sometimes leaving the patient hanging in the sense that their vision therapy program is not always complete.
Taking this insurance is probably the most time-consuming of all insurances, but because of our referral relationship it is worth the time and effort to work with these patients. We see these patients for an initial consultation and then we fill out an extensive form called a C-4 and then a C-4 Authorization form.
The C-4 details your findings and recommendations and the authorization form is writing out exactly what you plan for their treatment and follow-up schedule. In New York state, the Workman’s Compensation Board has 40 business days to determine if services are granted or denied. We do not start seeing the patient for vision therapy until we get approval, so often their treatment is delayed.
The one nice thing about taking this insurance is that once we get the approval we know exactly how much time we will have with the patient and can design their treatment plan accordingly. I will note that occasionally we do need to request additional sessions/exams, but these are sometimes harder to get approval.
Each school has its own nuisances, but typically we bill out to the patient’s private insurance and whatever is not covered then gets billed to the school for coverage. This is a fairly easy process, but occasionally the parents have to help coordinate with the insurance companies and retrieve the EOBs for us if we do not participate directly with their private insurance.
The easiest patient to deal with; they pay upfront from their vision therapy program or pay per session and if they request we will provide them with a CMS form to submit their insurance for reimbursement if their plan has out-of-network benefits. We also try to help the patients in any way possible so sometimes this requires a letter of medical necessity along with records and reports. We still offer CareCredit as an option, but only a handful of patients use this service.
So overall, is my advice the same as it was when I started this journey? Absolutely. Deciding which insurance plans work best for your practice model allows you to be efficient and profitable and is the best way to run your business. It will not look the same for each office, but it (literally and figuratively) pays to evaluate the panels you are on/want to join and if it makes sense for the way you want to practice, the services you provide, and your patient demographic.
My partner and I have discussed getting rid of some of these insurances and going completely private pay, but for now, we are not making any changes.
Is it scary? Will you lose patients? It can be, but you will be a better optometrist (and happier one) for making the necessary changes for your business.