Refractions: Understanding the Value

By Austin Stone October 22, 2020

Refractions are such a large part of our industry and seem to be undervalued and misunderstood in many scenarios. As many refractions that providers perform during the year, I often receive twice as many questions. We find that questions about refractions come from both the patients but also your staff. 

First, as a practice, you must define the importance of this routine test and the impact it has on the care you provide. Once the clinic defines its importance, understanding the "why" will help your staff relay this critical information to the patient. For example, a provider may use this information to explain why the patient's cataracts have changed their vision. During this exploration phase, you must also discuss cost. Refractions are not covered by Medicare, which in turn, is not covered by several commercial insurance entities. 

Most Common Reasons Insurance Claims Are DeniedI have worked at several clinics, and cost varies. While you do not want to be gauging patients with this out of pocket cost, you must consider the work that goes into them to define the best price to charge for your clinic. Generally, the charge is between $35-52 for the exam 1x per year. This annual charge will include any glasses re-check your patients might need; you will want to be sure you factor this in your cost. Charge too little with a high volume of re-checks and you will lose money. Charge too much, and you will have a dissatisfied patient. Having the right balance is key when it comes to this charge and exam. Do you know what other practices are charging around you? What efforts go into providing the patient this test? These components will help you determine a price that suits your practice and your patient.  

We must understand why Medicare does not cover this charge as part of the annual eye exam. Medicare defines refraction as part of the routine exam to get eyeglasses or contacts, which they also do not cover. Because it is not considered a medical test, your patient can and may opt-out of receiving the refraction. This must be discussed before the exam with the provider; covering the charge in your financial paperwork is the best way to accomplish this. In a busy clinic you certainly cannot question every patient, but your second checkpoint is with your technician. Having them discuss the test and the cost before performing it will avoid any additional confusion. 

Eye-Opening Ideas for Better Vision | Today's TransitionsKnowing your practice and why the refraction is important will help the patients understand why you are performing this exam in a clinical setting. In some circumstances, you can offer to bill the exam to their health plan, but we must clearly explain to patients that the insurance company might not cover the charge and they’ll receive a statement in the mail. As we know, the patient receives the statement and the amount owed from the insurance company often comes 30-45 days after claim submission. The patient can forget about your in-office explanation about the possibility of denial. The best way to approach this potential miscommunication is to help patients understand the Explanation of Benefits. Insurance companies don’t offer a class in reading these forms for patients. We should be proactive and help the patient understand their benefits. Reviewing the explanation of benefits with the patient in the words of the insurance company allows you to leverage the patient’s benefits to explain why this charge is their responsibility. As you walk through their benefits, simplify the insurance terminology, and if needed, refer back to your policies. You can also provide the patient with a receipt and suggest they submit through their vision insurance. Hopefully, they’ll get reimbursed directly for out of pocket expenses. Using these tools will help the patient understand why they are being charged and diffuse any conflict. 

What if the patient refuses and the provider needs the refraction completed anyway? In this circumstance, you do not want to stand in the way of the provider's plan of care. This charge will need to be adjusted, however, by tracking your provider and the number of adjustments you can present the provider with the information and see if there is another way to handle the situation. With the ever-changing healthcare marketplace, it is important for your provider to understand the cost of healthcare, but also ensure the provider knows the business side will not stand in their way of taking care of the patients. 

Streamlining the process is key to success in any practice. You want to be sure that each patient, every single time, is receiving the same information. 

To wrap it up, here are the key points and use this as your guide to streamline your practice workflow surrounding the refraction. 

   1. Have a clear understanding of how the refractions are incorporated into your practice - know the why!

   2. Determine a fair market value charge for the refraction and know that this is only charged 1x per year with their annual exam.

   3. Define clear financial rules - making sure the patient understands the expectation prior is key!

   4. Be flexible - know your providers and don't stand in the way of their care plan for their patients.

Refractions are often a daily occurrence in our industry and you may find that your staff or a patient is struggling to understand the cost and how this impacts their care.  Once you establish a communication protocol for dealing with refraction denials, you’ll manage patient expectations, increase patient satisfaction, and improve office productivity. 

Austin Stone

As a practice manager in the ever-changing field of Ophthalmology, I am excited to be apart of a community of support. I have been in the industry since 2017 with a focus on Revenue Cycle and Practice improvement. I have managed multi-specialty clinics and surgery centers down to single-provider practices looking to grow. I look to bring my passion and knowledge to this community to help your practice grow into everything you want it to

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