Vision therapy is amazing and it works! The only issue is getting insurance companies to pay because it is not cheap! There are ways to get it covered and there is so much gray area to be explored. I have been in vision therapy for two years and have done a ton of research to help myself and all of you figure out how to get vision therapy covered, here is what I’ve found.
How Can I Get My Insurance Company to Cover Vision Therapy?
- Call your insurance and ask if they cover orthoptics, vision exercises or the codes billed for vision therapy and if there are exclusions; Codes 99203, 99204, 92015 for Initial exams, codes 96111, 96116, and 92060 for visual information processing testing, codes 99213, 92060, 96111, and 96116 and code 92065 for weekly appointments.
- Get Prior Authorization using a detailed plan of care and letters of medical Necessity.
- Submit the claim after the appointment(s)
- File a detailed appeal with letters from Optometrists and Ophthalmologists, current research, and personal background if the insurance company rejects the claim.
There are so many optometrists lobbying for insurance companies to cover vision therapy and there have been great strides. If your diagnosis is convergence insufficiency, the chances of insurance coverage are much higher because there is more research. Many companies will cover 12 visits for that specific diagnosis. Diagnosis like strabismus and TBI are less likely to be covered.
This document was created by the American Optometry Association and is a gold mine of information regarding insurance and vision therapy. It is directed towards providers so it can get confusing with terminology. It is a great resource.
Working with insurance companies can be grueling and because so many refuse to cover vision therapy, some offices are strictly cash pay. The documentation and hoops to jump through require so much and if 75% of claims are denied anyway, I can understand why many vision therapy offices choose not to even get involved with the system.
if you are determined to get vision therapy covered by your medical insurance, there are three parties that all need to be onboard:
- Your Optometrist. Some insurances will only require an evaluation and plan of care, but others will want progress visits and appointment notes all documented with proper coding. Is your optometrist willing to do this?
- You. Are you willing to spend hours on the phone, and hours gathering research, and documentation and submit it to insurance. Sometimes I wonder if it would be better to just get a part time job.
- Your Insurance. Most states do not require insurance companies to cover vision therapy. It is up to every individual company to decide which benefits they will offer. They definitely will need to be onboard if you want them to pay.
I have called so many companies and done a ton of research, let me help guide you through the process of working with your insurance company to cover vision therapy.
How to discover if your insurance covers Vision Therapy
Ideally, your insurance company covers VT and you will get it all covered, unfortunately, this is super rare. Getting an insurance company to cover VT is going to require some leg work for sure. Most vision therapy offices do not even deal with insurance so you will be the one doing the work, not their billing office.
Step 1: Call Customer Service
Pick up the phone and dial the number on the back of your medical insurance card. I searched through endless online documents and there are a few companies that explicitly talk about VT (Aetna and Liberty Healthshare) , but most don’t mention anything. It’s easier to just call in.
Step 2: Ask if Vision Therapy or Orthoptics are Covered
Ask if Vision therapy is covered (also called vision training or orthoptics). If the answer is yes, there are a few additional questions to ask:
- Which diagnosis does the insurance cover? Ask about your or your child’s specific diagnosis. Don’t mention learning issues, instead mention binocular vision problems like strabismus or convergence insufficiency.
- How many sessions are covered per year? Sometimes there is a cap on the amount of money to be spent on vision therapy.
- Does treatment require pre-authorization? If so, ask for the specific steps to take.
- Which Diagnosis codes are covered? Codes 99203, 99204, 92015 for Initial exams, codes 96111, 96116, and 92060 for visual information processing testing, codes 99213, 92060, 96111, and 96116 and code 92065 for weekly appointments.
- What documentation is required from the Optometrist.
Step 3: Keep Asking Questions
Here is a mock conversation you may have.
You: Hi, I’m wondering if my plan covers vision therapy.
Them: No, this is a medical insurance and we have no vision benefits.
You: I totally understand, vision therapy is actually billed under medical codes.
Them: Oh, I haven’t heard of that before, let me check.
You: Try searching under “Orthoptics” or “Vision Training,” usually that is the name insurance companies use.
Them: I don’t see anything.
You: Can you try to look up whether a specific diagnosis is covered? (Convergence Insufficiency, Accommodative Dysfunction, strabismus, amblyopia, etc).
Them: *keeps digging
You: Explain the diagnosis, reason for treatment, etc. They are so much more helpful when they understand your plight.
Step 4: Ask About Specific Codes
While chatting, it may be helpful to get transferred to the claims department and ask if specific CPT insurance billing codes are covered under your policy. Codes 99203, 99204, 92015 for Initial exams, codes 96111, 96116, and 92060 for visual information processing testing, codes 99213, 92060, 96111, and 96116 and code 92065 for weekly appointments. These codes are used by other professionals like occupational therapists and ophthalmologists, so even if the codes work for them, they may not be accepted when billed through a developmental optometrist.
There is no reason to be frustrated. Most people have never heard of vision therapy so understand that you are helping educate and spread awareness. Be patient and willing to explain and listen and you will get so much further with the agent you are talking to. They can give you a quick and easy “no,” but if you are persistent they will keep digging and find out more information.
Even if the answer is that they do not cover VT, understanding their policy and why they choose not to will give excellent information that will help you make your best case for an appeal. Knowledge is power!
In my case, the answer was that there was nothing saying it couldn’t be covered, but it also wasn’t mentioned as a covered service. This is great news, they haven’t decided yet so there is time to convince them that VT is amazing.
From here, I was directed to get a “Gap referral” from a primary care doctor stating the vision therapy is medically necessary. Keep scrolling for details on how that process goes.
Get Prior Authorization
Some Vision Therapy services are billed through codes used by ophthalmologists, especially the exams and progress visits
Other services can be billed under codes for “Physical Medicine and Rehabilitation” which are normally used by Physical and Occupational Therapists.
Getting prior authorization or having something from the past covered is going to require detailed documentation; plan of care and progress notes with each appointment may be necessary.
My husband is a physical therapist and uses some of the same codes that some VT offices use. In order for some insurance companies to pay, he needs to spend 5-10 minutes per appointment documenting and then send those notes in. Your vision therapy office should be doing this, but be sure to check that they are willing to document and share with your insurance company.
This document is FABULOUS for Optometrists (or anyone who wants to know more) to read, feel free to share it with yours. It goes through so many details of the dos and don’ts and how to’s of vision therapy and insurance. It even has prewritten letters for specific situations that can be sent to your insurance company.
My favorite part was the end where the author goes through several specific binocular vision problems and shares research and evidence for the efficacy of vision therapy, incredible! Talk about a page turner! Everything you need to know and all the information that you need to provide your insurance company is located in that magical document. Thank you American Optometric Association!
For the cliff notes version, keep reading here.
Insurance Doesn’t Have a Policy For or Against Vision Therapy
If there are no specifics about vision therapy, most insurances will require a referral from a primary care physician stating that vision therapy from a developmental optometrist is medically necessary. If you have an ophthalmologist that is in support of VT, their referral is also beneficial.
It is important to understand that insurance will not approve of vision therapy because a child can’t read or an adult can’t drive. Those are side effects of a medical problem. The reason given to insurance must be a medical diagnosis.
Finding a physician who is aware and in support of vision therapy can be tricky. Call ahead of time and ask a nurse if they are willing to refer to vision therapy. This can save a copay or two or three.
Compile research pertinent to your specific condition that supports vision therapy (Find GREAT info in the magical document pages 55-end) and send it to your primary care physician (PCP) to review before your appointment. Ask your developmental optometrist for a letter of medical necessity to share with your PCP. Your optometrist may also have simple tests to help explain the problem to the doctor.
If/when they resist giving the referral, offer them the following:
Do you recommend physical therapy before surgery? Why would this not apply to strabismus? Strabismus surgery usually only lasts 5-10 years and even the first year only has a 70% success rate, vision therapy helps keep the eyes straight long term.
After you get a referral sent to the insurance company, they will review it and most likely send you a letter letting you know whether they are going to cover vision therapy or not.
If the answer is yes, hooray!
If the answer is no, keep reading.
Insurance Excludes Vision Therapy- File an Appeal
If your insurance company specifically states that they do not cover vision therapy or orthoptics or your request is denied, it is always possible to file an appeal. Every insurance company will have their own specific paperwork requirements so call and get the exact steps.
This type of appeal would be done before submitting a bill in order to get prior authorization. Make sure to follow your insurance company’s guidelines to a T and include anything else you can think of.
Having a letter of medical necessity from a primary care doctor or your ophthalmologist will do more for your case than anything. If you only include a note from you developmental optometrist, the claims department will see “optometrist” and immediately think, “we do not cover vision” and will be less accepting of your appeal.
Seeing the note from a medical doctor will mean much more to the insurance company, which gets a huge eye roll from me since they aren’t the ones performing the service, but at this point we are just trying to get coverage, right? That is a fight and discussion for another day.
The claims department will review your appeal and hopefully accept it and approve VT for you or your child. They will most likely only approve 8-12 visits, if any, and then require more authorization if additional VT is needed.
Submitting a Claim to Insurance
If you are not able to get prior authorization or you have already been to vision therapy, then it’s always worth a try to just submit a claim to your insurance.
In order to submit a claim, definitely check with your insurance company on their specific requirements, but in general you will need to submit the following:
- Itemized Bill
- Patient Name
- Date of Service
- Type of Service and any Procedure Codes
- Service Charges
- Diagnosis Codes in ICD Format
- Details about Healthcare Professional
- Name
- Credentials
- Address
- NPI
- Proof of Payment
- Letter of Medical Necessity from Optometrist and Ophthalmologist or Primary Care Physician
- Plan of Care
When Your Claim is Denied For Vision Therapy
Anyone else seeing a pattern here?
Try to get prior authorization- get rejected.
File an appeal- get rejected.
Submit a claim- get rejected.
Appeal the rejected claim-Get rejected.
But remember that at each step there are people having success and insurance companies are becoming more open to covering vision therapy. Trying and appealing are helping educate the world about vision therapy!
The appeal process when a claim is denied is similar to the process followed when a request for prior authorization is denied. There are a few extra items that are good to include.
- Submit a written request. Include supporting information just like with all appeals: Bills, medical information, letters of medical necessity, referrals, a plan of care, codes, studies etc. Many of those items can be found in the magic document.
- Request a peer to peer review. Many times a request or claim for vision therapy is denied because the case is “peer reviewed” by an ophthalmologist who doesn’t support the use of vision therapy. Peer reviews should be done by a peer, AKA another Developmental Optometrist (FCOVD), not by someone who treats the same body part. Request the peer review to be done by a FCOVD.
- For Strabismus, compare the situation to surgery/physical therapy. Physical rehabilitation should always proceed surgical intervention, it’s part of the medical code-or whatever they call it.
Good luck! I hope that you are able to have success! If you are determined, you can do this. We are doing the work for the next generation! And if you decide that it’s not worth the headache, there are plenty of other options for paying for vision therapy.
Your Insurance Doesn’t Cover Vision Therapy. Now What?
If you’ve exhausted your time and resources in pursuit of insurance coverage and it just isn’t happening, don’t despair! I have some great ideas to help you figure out how to pay for vision therapy. You’ve got this!
Option 1: Don’t Do Vision Therapy
I don’t recommend this option, but it is a choice. People have survived this world with a lazy eye, double vision, blurred vision and all sorts of issues for hundreds of years. Is it ideal? No. But it will build character, so that’s always fun.
I think it is powerful to remember that it is a choice.
If you are determined to make it happen, here are my best ideas for paying for vision therapy!
Step 1: Change Your Thoughts!
After finding out the cost of VT, most people think, “I will never be able to afford this.” or “This is impossible!”
The problem with those thoughts is that they make you want to eat bon bons, watch Netflix and complain to your friends, all terrible ways of raising the funds for vision therapy.
Instead, empower yourself with curiosity. “I know I will make this happen, I can’t wait to see how I raise the funds!” and “I wonder how I am going to figure this out” are going to get your brain working on finding solutions. Your brain is AMAZING at finding solutions to problems, just let your brain do the work, it’s already as good as done.
Use Other Covered Professionals to Help
There are occupational therapists who help with retained primitive reflexes (an important aspect of vision therapy success), most OT is covered under insurance plans. Even doing it simultaneously with the VT can help the patient progress more quickly and could translate into fewer appointments being needed overall.
If your developmental optometrist doesn’t work with insurance, get glasses prescriptions from a traditional optometrist who can bill vision insurance.
Some ophthalmology offices offer orthoptics and different home programs with appointments every few months. Finding an optometrist who will work with the ophthalmologist and visa versa might be hard, but getting some of those home programs covered by insurance could really help save some money.
These professionals can all communicate together to help you! Sometimes they get competitive with each other and you may run into trouble there, but it’s worth a try! There is definite overlap between the professions.
Create An Alternate Schedule with Your Vision Therapy Office
Depending on the diagnosis, sometimes appointments can be every other week or even once a month. I prefer going weekly and I feel like it makes a difference and I progress so much more quickly, but others have had success going less often, especially for younger children less than 5 years old.
Paying for a home Vivid Vision or Optics Trainer Subscription for virtual reality can help keep that home-office connection even when there are multiple weeks between appointments.
Make Extra Money to Pay- 10 Ideas
Vision therapy can cost between $400 and $800 a month depending on the office you attend and the frequency of appointments. Making that much extra a month is hard, but not impossible, here are some ideas for scraping up an extra $500 or so every month. Spoiler alert: The best way to make more money is to spend less.
- If you don’t already, start filling out a budget weekly or monthly to keep track of spending. Just watching the money come in and out creates so much awareness and you will naturally be smarter with the money that you have.
- Ask for a raise if you deserve one, if you don’t, work hard and earn that raise, this can generate extra money very quickly.
- Have a garage sale or list items like old phones or electronics on Facebook marketplace.
- What is your specialty? Can you become a private tutor for that subject? Private tutors make between $25 and $50 an hour. Math, science, language and reading tutors are popular subjects for academic tutoring, but don’t forget about sports too! Parents will pay a pretty penny for one-on-one training for their sport, can you teach tennis, soccer, or basketball lessons?
- Start a bake sale. This was my bread and butter for paying for my vision therapy in 2020. Each week I would make bread, cookies, cinnamon rolls, pico-de-gallo and gather garden veggies and set up a table at the corner of my road. I advertised on community Facebook pages and paid my kids or neighbor kids to run the stand for me. I went from profiting $50 the first week, to making between $200 and $300 per week by the end of summer. It was work, but also quick money! If you need recipes, I’m happy to share, just leave a comment!
- Get a job- I know, so boring and predictable, but I had to throw it in there. Are you a responsible, capable adult? If yes, then you are rare and companies would be delighted to hire you, even if only for one day a week. Good workers are hard to come by! If you already work, is there a way for you to pick up an extra shift or even work a few extra hours every week?
- Cancel Subscriptions- We live in a subscription happy world! So many offers of “free trials” turn into $10 a month payments that we forget about. I was able to save over $100 a month by simply canceling subscriptions that I wasn’t even using.
- Apple users can go to settings and search “subscriptions” and remove any unwanted subscriptions to different apps all in one place. I’m sure Android is similar
- If your subscriptions are through PayPal, you can remove them all at once in settingsl.
- Do you need Direct TV, Hulu, Netflix, Peacock, Amazon Prime AND Disney Plus? We rotate and trade out every 6 months or so and it saves about $30 a month and makes it more fun when we switch to see all the new items!
- Check your Amazon subscribe and save settings. Are there items you’ve subscribed to that you don’t need? How about audible? I had 8 credits saved up on audible and I wasn’t even using them. I was able to actually get refunded for several months by calling in.
- What direct sales companies are you subscribed to for protein powder, beauty products, food, or cleaning supplies? Even if you still use the products, consider pausing your subscription for a month or two until you actually need the products again.
- How about subscriptions to fun monthly boxes? Whether it’s science projects for your kids or clothing for you, could you order or shop for those items on an as-needed basis instead of getting them monthly?
- Change the way you eat out. Ideally, you would just stop eating out, grow your own food and save hundreds every month, but that isn’t very realistic for most people. What sustainable changes can you make?
- Order water instead of a drink
- Choose restaurants that are less expensive. There are so many options for delicious, healthy food for $7-10 a plate instead of $15-20 a plate. Making this shift can save money, especially if you form new habits! Most places have online menus, check the prices before you go.
- Skip appetizers and desserts
- Buy pre-chopped veggies and fruit or pre-seasoned meat at the grocery store. It still saves time and prep work and tastes delicious, but is much less expensive than eating out.
- Change your vacation to a stay-cation. Vacations drain resources SO quickly. Instead of a $5000 family trip to Disneyland, use $500 for a stay-cation. My kids LOVE staycation and so do I. We go out for breakfast, visit trampoline parks and roller skating rinks and other around town places and then come home and sleep in our own beds. We let each kid and adult pick one out to eat and one activity for the week and we have a blast! I’m not saying to do this every time, but for a year or two, it’s okay to make the sacrifice and it will save thousands.
- Get rid of high payments. Do you own furniture, vehicles, or toys that aren’t paid for? Sell them, pay off your debt and get something you can pay cash for. So boring and painful, I know! You may not choose to do option 10, but it is good to acknowledge that it is a possibility and a choice. For me, I’d rather drive my 15 year old, dented and scratched up mini van for another year or two and have the money to pay for vision therapy, then get the new suburban that would be so so nice to have!
Is your brain going yet? There are so many possibilities for making a saving money, I know it is possible for any of us to make the money and pay for vision therapy if that is your goal. Believe that it is possible, then let your brain do the rest. You are brilliant and 100% capable of figuring this one out.
Arrange a Trade or Get Hired By Your Vision Therapy Office
Through my instagram, I have met so many fellow vision therapy patients and I have heard several different creative ways they have gotten their VT paid for:
- Becoming a VT and working for the office
- Trading VT appointments for piano lessons
- Trading graphic design for VT appointments
- Managing the office social media
- Helping film “commercials” and Ads for the office
What skills do you have? What skills can you learn? Get excited and the ideas will start flowing!
Get it Covered By Your School District (for kids)
Most states do not offer vision therapy as a service in their schools, but more and more are starting. It is very common in states like New York and California, but in states like Idaho, it is much less likely.
Public Law 94-142 is known as the Education for All Handicapped Children Act (EAHCA) of 1975. It guarantees free, appropriate eduction to children ages 3-21 and is the landmark federal legislation used for children with disabilities.
In order for a school to cover vision therapy, your child will need an IEP showing that they have visual problems that are affecting their academic performance.
Some schools will offer in-house “vision therapy” done with an occupational therapist. While this is fabulous, it won’t have the same effect as in-office vision therapy. It would be a great addition to vision therapy though!
Apply for a Grant (Ages 3-21)
Every state has grants for children with disabilities to get the services that they need. The application process varies from state to state. I recommend doing a google search of “___________(your state) grant for children with disabilities.” Some ads and fake sites will appear, sift through and find the one with a .gov address.
Once there, find out the requirements and fill out an application. Calling and talking to an actual person simplifies the process immensely. Again, your child will need an IEP for the visual problems before you are able to get very far in this process.
Get New Insurance and Wait
If your current insurance doesn’t cover vision therapy, you can always change insurance companies and just wait to start vision therapy.
Most individual plans do not cover vision therapy, but it is more common on high end group plans. If you work at a company that gives killer benefits and amazing group health insurance, you probably won’t have a problem paying for vision therapy though.
You can always talk to your employer about adding vision therapy benefits to your group health insurance plan.
Upgrading your insurance to a level that covers vision therapy could mean paying premiums $500-1000 more per month so it would be better to just pay for vision therapy out of pocket.
Care Credit
Care credit is basically a credit card used for medical expenses. You must apply (link here) and be approved first. As long as monthly payments are made and the loan is paid off within the designated time period (between 6 and 24 months), there are no interest charges.
If you are sure you can pay it off within the specified time, this is a great option and can help spread the cost out over a longer period of time.
If you don’t pay it off in the required time, interest is added and calculates from the beginning of the loan. At 15%, this can add hundreds of dollars to your overall cost so be careful!
Conclusion
Vision therapy takes time and resources, but it is well worth the investment. Improved vision and depth perception opens so many possibilities for both adults and children.
Vision therapy is proven to improve binocular function and fix a host of visual disorders. Because it is new, health insurance companies aren’t all on board with covering it. If you present them with scientific research and the proper referrals, getting all or a portion of vision therapy covered is possible! If the insurance route doesn’t work, explore other avenues for covering the expenses, there are so many possibilities, all you need is one.
Invest the time and hard work now and reap the rewards for a lifetime.