Coordination of benefits: 3 takeaways for optometric billing practices

Coordination of benefits (COB) is more than a question of who’s paying—or who pays first—it’s about maximizing patients’ benefits by saving them time and money. 

The Centers for Medicare & Medicaid Services (CMS) defines COB as applying any time a beneficiary is covered by more than one plan, permitting Medicare, in this instance, to coordinate with other plans or payers to reduce administrative burdens and enable patients to obtain payment of the maximum benefit allowed. COB claims are those sent to secondary payers with claims adjudication information included from a prior or primary payer obligated to pay first. 

But COB in eye and vision care is different than that utilized by the medical industry as a whole—and it’s not as straightforward. 

“Coordination of benefits is an essential concept that allows patients to utilize the vision benefits that they or their employer are paying for but may not be able to otherwise utilize due to medical conditions that require visits under their medical plans” says Steven Eiss, O.D., AOA Third Party Center (TPC) Executive Committee chair. “Although some vision plans already utilize some form of COB, there are specific plan requirements and limitations that may prevent full utilization.”  

The goal of the COB between medical and vision plans is to allow a patient to utilize a paid for benefit, e.g., routine eye exam, when they have a medical eye condition that would preclude them from utilizing the benefit otherwise. Without COB, that would mean a medical eye care patient could only utilize their benefit by returning for an additional office visit, resulting in an additional copay and repeated examinations. 

Those specificities between plans mean COB transactions can be especially confusing, yet that’s where the AOA TPC hopes to help. The AOA TPC advocates for the inclusion of doctors of optometry in all medical eye care, whether provided privately, publicly or through any third party arrangement.  

Dr. Eiss, as well as AOA TPC committee members Jason Ortman, O.D., and Andy Stephens, O.D., offer AOA members three takeaways to keep in mind with COB transactions: 

1. Review your provider manuals for the COB process. For example, Dr. Eiss calls attention to how some, but not all, EyeMed plans will coordinate payment for noncovered refraction only when performed with a medical eye exam. EyeMed usually updates this list periodically. The list can be found in EyeMed’s Provider Manual online. VSP has a COB benefit on many, but not all, plans that can be utilized toward both refraction and examination when not paid in full by the medical plan. VSP has information and training on its Provider Hub Website. Dr. Eiss says: “It’s essential to refer to the provider manual to ensure that the patient’s plan allows for COB. The AOA TPC has been advocating for a full-range COB for all components of a medical eye exam by all vision plans, allowing patients to utilize all the benefits that they are paying for while still receiving the medical eye care they require.” 
   
   
2. Patients must initiate changes to their primary or secondary insurance. Medicare forwards claims to secondary insurers automatically in situations where Medicare is the patient’s primary insurance. For most commercial medical insurers, secondary claims require a copy of the primary explanation of benefits when being filed, Dr. Stephens notes. If a patient hasn’t updated their insurance company properly regarding changes to their primary or secondary, the claim will be denied as “needs COB.” This step has to be accomplished by the patient contacting their insurance company for corrections and cannot be done on their behalf. 
   
   
3. Understand that COB saves patients money and multiple visits. Dr. Ortman emphasizes that not every plan will coordinate benefits; it varies by plan and employer. However, if eligible, then COB allows patients to utilize their routine benefit allowance toward uncovered portions of the medical eye exam and refraction. Most vision plans won’t cover the amount of the medical deductible/copay above what the plan typically reimburses.  

COB is only applicable when a medical exam is performed in conjunction with a refraction. Both are billed to medical first, then once an explanation of benefits is received, this can be passed along to the vision plan for documenting copays, deductibles or noncoverage. These are then covered up to the dollar amount of the exam benefit. 

Experiencing difficulties with a health or vision plan? Report these challenges to the AOA TPC at stopplanabuses@aoa.org.