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 addresses 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:
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.
In 2014, no insurance plan is 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 8 sessions in 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 therapy isn't all bad. Once you have figured out a system to see if 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 insurances. 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.
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 service 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 insurances.
Each doctors 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.
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 of me not 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.
I often have to remind myself that [Tweet "Anything worth doing isn't easy!"]
Like I said in the beginning of the post, I mulled over this question for weeks, even months before coming to my decision. Then a month into working full-time I had to change my game plan I had spent so much time working on. Depending on your situation, your decision may vary from mine. You have to do what works for you and your business!
As with anything, you have to make things your own. This article was designed to help you start thinking about the things you need to consider when starting a business. If you have any questions, please feel free to comment and I will do my best to answer them! Good luck!