Turning Problems into Profits

EyeMed No Longer Coordinates Medical Exams


EyeMed has changed their medical coordination policy for refractions.  Many medical payers do not cover refractions because they are routine in nature, but EyeMed has always paid for these refractions under the patient’s routine exam benefit when medical claims were coordinated. This changed in November; EyeMed no longer covers refraction-only COBs.  When we questioned EyeMed representatives about this change, we received a variety of answers, from refractions are content of service to an exam (which, of course, is not correct according to the CPT manual) to EyeMed wants to ensure patients get comprehensive examinations (which their medical EOBs clearly show they did).  A few weeks ago we talked to a senior official at EyeMed and were told that, except for a handful of plans, EyeMed contracts do not cover coordinations, and they were just trying to get claims processing back in line with their contracts.

Whatever the reason, this policy change denies many EyeMed patients access to their exam benefit.  For patients with medical conditions or eye diseases, the refraction is the only routine professional service they will receive during the year. EyeMed patients must now pay for the routine portion of their exams even though they have routine coverage.  At the very least, this policy financially penalizes patients and, at the very worst, has the potential of interfering with appropriate patient care if patients elect not to proceed with a medical exam because of the financial barriers EyeMed has imposed.

OBS currently have unpaid refractions sitting on patients’ accounts from COBs which EyeMed denied. We confirmed with EyeMed that these are patient responsibility and not a contractual write off, so we will be transferring these balances to patients with a note that EyeMed denied their claims.  Moving forward, you will need to collect the refraction from your EyeMed patients if their exam is medical. If you encounter unhappy patients, offer to give them EyeMed’s number.  The EyeMed official we spoke with did say that the company may consider revising this policy in the future, and he welcomed calls from offices and patients who had concerns.

This process only affects EyeMed patients, not VSP.  VSP has always placed a high value on customer service, and they automatically allow coordinations except for a few plans which specify otherwise. (If it helps you remember, think of it as an inverse ratio:  EyeMed only has a few plans we can coordinate, but VSP only has a few plans for which we cannot.)  VSP pays up to $66 under coordination, less the patient’s copay.  It is only EyeMed patients for whom you will have to collect the refraction at time of service.

If you have questions or concerns about EyeMed’s no-coordination policy, do not hesitate to call your coordinator–and EyeMed!