For today’s blog post, we would like to feature an article that was published by The College of Optometrists in Vision Development (COVD). It is a very helpful guide when dealing with insurance companies for coverage of any vision therapies like Vision Restoration Therapy or NeuroEyeCoach.
Vision therapy is used to treat diagnosed vision conditions. In some cases, Vision Therapy is the only available and effective treatment option for these conditions. This treatment may be covered under major medical insurance plans. However, some insurance companies and managed care plans may deny or place severe limits on coverage for Vision Therapy services as a cost-saving measure.
Under all forms of medical insurance plans, you, the consumer and/or patient, have a right to request a review of any service that is denied coverage, or for which coverage is severely limited. If you believe your plan has incorrectly evaluated the claim for coverage, acted arbitrarily, or discriminated unfairly in determining coverage, you should seriously consider requesting a review.
Steps to Consider in Requesting a Review of Denial of Coverage for Vision Therapy
1. First, review your medical plan’s Explanation of Benefits booklet to see if there is any statement about the inclusion or exclusion of coverage for Vision Therapy or Orthoptics. Some plans explicitly exclude overage for these services.
Some plans may exclude coverage for Vision Therapy to treat educational problems such as learning disabilities, dyslexia, etc. The treatment of learning problems and dyslexia are educational problem that are not within the purview of major medical insurance coverage. However, this should not preclude receiving coverage for Vision Therapy which is treatment of a diagnosed vision problem.
2. Ask for a written statement on the exact reason that coverage was denied or limited. If an arbitrary statement is given that the company or plan concluded that Vision Therapy is not considered medically necessary, or is not effective in treating the diagnosed problem, ask for documentation to support that claim.
Many research studies and clinical reports have been published that support the effectiveness of Vision Therapy/Orthoptics. Unfortunately, your insurance company or plan may not have reviewed this information.
3. Some insurance plans may indicate that the services were reviewed by their “medical consultant” who recommended the services not be covered. You may wish to inquire as to the qualifications of the consultant, especially in regard to the area of determination (i.e., was it a Doctor of Optometry?).
It is common medical practice for questions regarding the medical necessity or appropriateness of treatment to be reviewed by a “medical peer,” another doctor with similar training and knowledge in the particular area of care. If the claim for Vision Therapy services was not reviewed by an optometrist who also provides these services, then true “peer review” did not occur.
The College of Optometrists in Vision Development (COVD) is an international certification body for doctors who provide Vision Therapy services. Fellows of COVD (FCOVD) are Board Certified in Vision Development and Therapy. To obtain true peer review services for Vision Therapy, you may request your claim be reviewed by a Fellow of the College of Optometrists in Vision Development, or by the Peer Review Committee of the College.
4. When claims are denied on the basis that the insurance company or their consultant believes there is a lack of sufficient research to support the effectiveness of Vision Therapy, Supplying documentation of available research may result in approval of coverage.
5. If after going through the above process, coverage of your claim for Vision Therapy is still denied, you may want to consider the following actions:
- If your medical insurance coverage is provided by your employer, bring the problem to the attention of your company’s Employment Benefits Manager and ask for his or her assistance.
- If you purchase insurance coverage yourself, contact your insurance agent and ask for help in getting your claim paid.
- If you are unable to obtain satisfactory resolution of your claim, consider filing a complaint with the office of your state commissioner of insurance.
It is important to remember that the unwillingness of your insurance company to pay for these services does not reduce the need for obtaining treatment. Talk with your doctor about payment options that may be available to assist you or your family in obtaining needed care.