Understanding Health Insurance and Vision Therapy

Naturally, you have two questions when you learn your child needs vision therapy:

1. How much therapy will I need?

Reading: How to get vision therapy covered by insurance

2. How much will my health insurance cover?

The answer to question #1 depends on the results of your functional vision test and the progress you make with your doctor and therapist. the answer to question #2 is a bit less specific.

When our daughter needed vision therapy, our insurance didn’t cover it. Naturally, she disappointed us, but we found a way to pay for the therapy out of pocket (I’ll talk about some creative ways to pay in a future post).

I asked vision therapy center office manager kim jelinske why vision therapy isn’t covered by most health insurance plans. The answer took me further than I really wanted to travel into the intricacies of health insurance, but I bit the bullet and tried to distill the answer as best I could.

This article applies to the vision therapy center. our vision therapists may have a different approach. We wrote it not only for the benefit of our current and future patients, but also to create discussion in the health insurance and vision community.

here it goes.

understand the usual and customary fare

Kim described to me how it works: The vision therapy center charges $139 for a vision therapy session. Insurance company A decides that they will only pay us $69 for one session. that’s a $60 gap between our costs and what insurance will cover.

so how did the insurance company come up with the $69 fee? The amount is what insurance companies consider a “usual and customary rate” (UCR) for a service. A UCR is supposed to be conducted by an independent party that takes into account similar services offered in a specific geographic area.

Based on the $60 difference in the example above, you might assume that the vision center is overcharging for your appointments, but that’s not true. the “independent parties” have to try to find similar services offered in a geographic area. Unfortunately, there are very few places that perform the level of vision therapy that dr. kellye knueppel and his staff. As a result, the ucr is often too low.

why the ucr prevents us from becoming a provider of your insurance company

Now here’s the real sticking point for us. If we become a provider for your insurance company, we will not be allowed to charge more than the UCR amount. For example, at the $69 UCR, the insurance company could cover $64, and perhaps make the insured pay a $5 copay. so what would happen to the remaining $60 of our costs?

If we were a provider, our contract would say that we can’t ask the patient to pay the rest, or give them what’s called a “balance bill.” (There’s a scenario where we can do that, and we’ll get to that in a second.)

We would have to cancel the $60 or increase our rates on other patients to help cover the shortfall. Since we need to cover the costs to keep our doors open, we did not choose any option and are left with the following payment scenarios.

We are not a provider with your insurance company, but your insurer will provide a ucr for vision therapy. In this scenario, we are not part of your insurance company’s provider network. If you choose to have vision therapy performed by us, your insurance company will cover the UCR and make you pay both the copay and the “balance bill” (mentioned above).

here’s how it works: insurance company a, for which we are not a provider, will pay us a total of $58.00, which is your ucr. You will be asked to pay the copay, which we will say is 30% of the ucr, or $17.40. in addition to the copay, you will have to pay the “balance bill” of $81.00 for a total cost to me of $98.40.

Remember, if we had chosen to be a provider in your network, we would have been forced to write off that “balance bill”, which would not have been financially feasible for us.

We are a provider for your insurance company, but your employer has chosen to exclude vision therapy from their policy. There have been cases where a prospective patient discovered that we are a provider. for your insurance. however, that doesn’t necessarily mean your policy covers vision therapy.

why not? Well, to get a lower rate from insurance companies, employers often negotiate coverage packages and may choose to exclude certain coverages. If your particular policy does not cover vision therapy, your costs will not be covered, even if we are a provider.

This is why we advise everyone to carefully review their policies.

Your insurance company does not cover vision therapy at all. Unfortunately, these cases exist and you will have to pay the costs out of pocket.

As if you hadn’t guessed yet, insurance coverage can be a very complicated thing. If you need vision therapy, let us help you understand how to ask your insurance company the right questions and determine if you’re covered.

Almost everyone has a different scenario, which is why Kim Jelinske works so diligently with each of our patients to cover all bases. In the future, we hope that insurance companies and employers will realize the benefits of vision therapy and include it in their coverage.

It would make things less expensive and a lot less hassle for everyone involved.

(photo by tara kuhlow)

The Vision and Learning Guide from The Vision Therapy Center. Learn how undetected vision problems can impact a child’s ability to learn. Download your free Vision and Learning Guide.