Today we’re keeping $225 in our pockets because I clicked on a link in the member portal of Mr PoP’s vision insurance and checked Mr PoP’s benefits even though I was 99% sure a bill wouldn’t be covered.
Mr PoP has risk factors for glaucoma that means he should have been getting regular visual field tests after he passed age 30. Getting Mr PoP to the doctor for something non-urgent is a challenge, so I finally got him to an appointment last month for this exam. A year later than he really should have gone. =P
Everything we’d been told about this test, by the eye doctor and by Mama PoP who has had many of these tests herself over the years, was that these tests are always billed through medical insurance, not through vision insurance. Mr PoP has a high deductible health plan, so we *knew* going in that we’d be footing the bill to pay for the entire exam since he’s never been anywhere near his medical deductible.
Specialists can be pricey on Mr PoP’s HDHP, but the $250 the exam was going to cost wasn’t a reason to not get it done. If Mr PoP was headed down the road to glaucoma, it’s better to find out as early as possible. So we scheduled the appointment, and Mr PoP went last month. His results were great, so no worries there. =)
But Mr PoP didn’t pay the full balance like I thought he would the day of the procedure, just 10%. So I *knew* we’d have to pay more. Fast forward to the end of the month and we get the EOB (explanation of benefits) from his medical insurance company that the eye doctor ran the exam through. I wasn’t surprise it said we’d need to cover the entire amount, and have just waiting on the bill from the eye doctor for the rest.
Instead, something else happened. We bought Mr PoP those $950 glasses.
And since those were an out-of-network purchase, I logged into VSP (our vision insurance provider) to fill out the online out-of-pocket reimbursement for our purchase. (We’ll get ~$100 from VSP toward the lenses and frames.) It was the first time I had ever logged in to the VSP portal, but wanted to try doing it online rather than mailing or faxing the claim form since I was told by a coworker it was much quicker online.
Turns out, the claim form for the glasses was quick and easy online. So much so, that while on the VSP site I started clicking around a little – looking up Mr PoP’s benefits to see exactly how much we’d be getting for the lenses and frames. And then another link caught my eye. There was a menu of “Specialty Services” that are covered under Mr PoP’s plan.
Since he had just gotten this visual field test, I clicked. “Surely the test won’t be covered,” I thought. “Our eye doctor would have billed VSP as they have for other WellVision exams rather than going through the medical insurance if that were the case.”
But I clicked. And read:
“For the treatment and diagnosis of eye conditions like…glaucoma.” That sure as anything sounds like the exam that Mr PoP just had done. Is it possible it’s covered, even with the caveats about limitations and coordination with medical covered?
I Called The Eye Doctor’s Office
“Those exams are medical. We NEVER run them through anything but medical insurance. VSP won’t cover them.” said the office manager at our in-VSP’s-network eye clinic.
“Well,” I said, “This really reads like it might be covered under his vision insurance. Can you try to run it through VSP and see what happens?”
“If I do, it’ll force him to lose eligibility for his next WellVision appointment which is three weeks from now.”
“Really? That seems weird since they have different copays and the benefits read like they’re not mutually exclusive. How about you send me the detailed list of the billing codes for this exam and I’ll call VSP myself?”
(In actuality this conversation was much longer with the office manager not listening to what I was asking and being very dismissive. But after 5 painful minutes she agreed to fax me a statement that showed Mr PoP’s diagnosis code and the billing codes for the various exams that Mr PoP had as part of his visual field test appointment.)
Fax In Hand, I Called VSP (The Vision Insurer)
After making my way through the automated phone maze, I finally reached a person – Katherine! I explained to her that I was just reading my husband’s benefits and it looked like a vision exam he recently had might be covered under VSP even though our eye doctor was insisting it be run through his medical coverage (where the entire cost was being pushed through to us since his deductible hadn’t been met there).
She looked up Mr PoP’s exact benefits, and I filled her in on the billing codes and the diagnosis codes. “This should be covered, but you do have a $20 copay.”
“I’ll gladly take $20 over $250! And will using this benefit for the appointment he had last month prevent his from using the benefit for his WellVision appointment in a few weeks?”
“Absolutely not. You just can’t use them on the same day.”
“That’s weird, but okay.”
“Yeah, it’s a requirement.”
Katherine then called our eye doctor and spoke with the same office manager who was giving me a hard time and told her to run it through VSP since it was covered under Mr PoP’s plan. Apparently the office manager was tough to convince since Katherine was on the phone with her for 15 minutes while I waited on hold. But when she came back, she assured me that they eye doctor would run it through VSP and the only amount due would be a $20 copay.
And since Mr PoP had already paid $25, we’ll actually have a small credit on the account.
All VSP Plans Are Not Equal
Now curious, I logged in and checked the benefits on my own VSP plan. (We have the same vision insurer, but get our benefits as individuals through our respective employers.) There, it looks like I would have coverage for this stuff if I have a diagnosis of glaucoma, but doesn’t include services relating to the diagnosis itself. So for me, the eye doctor would have been totally correct to not run it through our vision insurer.
There are apparently so many different tiers of benefit plans that not even the doctor’s office can keep track of them these days. It’s hard to fault the office manager who really did think she was right for not using the VSP benefits for the visual field test since I’m guessing Mr PoP’s plan is in the minority, though I think she could have been a bit less dismissive of me asking.
But the 30 minutes I spent on this (and 20 of those minutes were spent on hold), were well worth it. Not only will we avoid paying an extra $205 this year, this is a test that Mr PoP should really be getting done regularly, so we’ll avoid paying it going into the future as long as Mr PoP has this vision insurance plan as well.
So let this be a friendly reminder. When in doubt about insurance benefits, it doesn’t hurt to check with your insurer. And it makes the call go much easier if you can do it with the diagnosis codes and billing codes in hand.
Now I just need to figure out how to get Mr PoP to show up for two different eye doctor appointments each year since they can’t be on the same day!
* I’ve tried scheduling our appointments together, especially now that we are a one car household [LINK to One Car], but that hasn’t always worked to get him there either and just ends up with us canceling or re-scheduling appointments at the last minute.
When was the last time you checked your benefits? Does your employer provide benefits that you’re not aware of and aren’t taking advantage of?