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Assessing Vision Plans

 

Assessing which vision insurance plans to accept is a strategic financial decision for any optometric practice. Accepting the wrong plans can erode your margins and overload your schedule with low-reimbursement patients. The right plans, however, can drive patient volume and profitability.

 

Here is a structured approach to assessing and selecting the right vision insurance plans:

  • Understand Your Market/ Demographic & Employer Analysis

    • What are the major employers in your area? What plans do they offer their employees (e.g., VSP, EyeMed, Spectera, Davis, etc.)?

      • Use tools like Zocdoc, LocalMed, or Pearl Vision Locator

      • Call HR departments of major companies that produce your patients or ask your patients during intake: “What plan do most of your coworkers use?”

    • Check competitors: What insurance do nearby offices accept? Can you offer alternatives?

    • Do you need to accept another plan? Is your schedule already full? 

      • If you want to grow, increase the amount of vision plans. If you want to grow profit, do not add or decrease them. ​

  • Evaluate Reimbursement Rates

    • Request Fee Schedules:

      • Directly contact each vision plan and request their fee schedule.

    • Carefully review:

      • Routine exam reimbursement

      • Contact lens fit reimbursement

      • Spectacle lens reimbursement

      • Frame allowance + discount structure

    • Compare With Your Retail Pricing:

      • Are you making a profit after lab costs and chair time?

      • Are discounts so deep that your frame sales suffer?

      • Does the plan allow for patient balance billing above allowance?

  • Calculate Break-Even Per Plan

    • Here’s a quick framework to assess profitability:

      • Exam reimbursement: $45

      • Contact lens eval reimbursement: $35

      • Average materials revenue (after plan discounts): $150

      • Cost of goods (lenses, lab, frame): $100

      • Staff time (billing, scheduling, dispensing)~$25/hour

    • Do you profit $100+ per patient?

      • If not, it may not be worth it, especially if the volume is low or patient compliance is poor.

  • Assess Administrative Burden

    • Billing complexity: Some plans can be a nightmare with authorizations, material restrictions, and paperwork.

    • Lab restrictions: Some require you to use their labs (lower quality, lower reimbursement, longer wait times).

    • Credentialing time: Some take 6–12 weeks to get approved.

    • Ask your team which plans cause the most headaches. These are plans that you might want to drop. 

  • Analyze Patient Volume Potential

    • Estimate how many new patients a plan could bring in:

      • Ask the insurance rep: “How many members are in my zip code?”

      • Talk to existing patients about which plans they wish you took.

    • Run a report in your EHR on insurance usage by patient. If you are seeing a surge in one plan, that may guide your decision. Also look at the revenue that the plans is bringing in. 

  • Balance a Healthy Mix

    • You want a diverse payer mix:

      • Some high-volume, low-reimbursement plans can fill your schedule. 

      • Others offer lower volume but better margins, which is better for profit. 

    • Aim for a balance: 1–2 high-traffic plans and more higher-margin plans.

  • Negotiate & Upgrade

    • If you are already on a plan:

      • Ask for tier upgrades (e.g., VSP Premier, EyeMed Access Enhanced).

      • See if you qualify for better lab contracts.

      • Push for frame board credit incentives.

      • What other incentives can the plans provide? 

  • Track Plan Profitability Over Time

    • Use your practice management software or EHR to track:

      • ​Average revenue per patient by plan

      • Capture rate

      • No-show/cancellation rates

      • Claim denial rate or delays

      • Lab redo rate

    • Even a popular plan may need to be dropped if margins are shrinking.

    • Look at your plans yearly and always consider dropping your lowest paying plan. ​

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