Our Policies
Vision vs. Medical Insurances
Understanding Your Insurance: Vision vs. Medical
Navigating insurance can be tricky. At our practice, the type of insurance used for your visit is determined by your Chief Complaint (CC) - the primary reason for your visit - and the doctor’s final diagnosis.
1. Vision Insurance (Routine Coverage)
Vision insurance (e.g., VSP, EyeMed) is a wellness benefit designed to provide a routine "check-up."
When it is used: For wellness exams, checking your prescription for glasses or contact lenses, and screening for general eye health.
What it covers: Refractions (the test to determine your prescription) and a basic screening of the eye’s health when no medical symptoms are present.
2. Medical Insurance (Advanced Care)
If your visit involves a specific medical concern or the management of a chronic condition, we must bill your medical insurance (e.g., Blue Cross, Medicare, UnitedHealthcare).
When it is used: If you are experiencing symptoms like redness, pain, floaters, or dry eye, or if you have a pre-existing condition such as glaucoma, diabetes, macular degeneration, or keratoconus.
What it covers: The diagnosis, treatment plan, and long-term monitoring of eye diseases.
Note: Medical insurance typically does not cover the refraction (the "which is better, 1 or 2?" test), which may result in a separate out-of-pocket fee.
3. Coordination of Benefits
In some cases, we may be able to coordinate both. For example, your medical insurance may cover the health portion of the exam, while your vision plan provides a "materials benefit" toward the purchase of your frames or specialty lenses.
Medical Eye Care - "Multiple Visits “Confusion”
Why Medical Eye Care May Require Multiple Visits
A common misconception is that a patient is only "allowed" one eye exam per year. While vision insurance (wellness plans) typically covers only one routine check-up annually, medical insurance works differently.
Because your eyes are vital organs, the management of medical conditions often requires more than a single annual visit.
Medical Necessity: If you have a condition like glaucoma, macular degeneration, or diabetic retinopathy, your doctor may require follow-up visits every 3, 4, or 6 months. These visits are medically necessary to monitor disease progression, adjust medications, or perform specialized diagnostic testing (like OCT scans or visual fields).
Specialist Care: Just as a heart patient sees their cardiologist multiple times a year, an eye patient with a medical diagnosis requires ongoing specialist care. Your medical insurance covers these visits based on the complexity of your condition, not a calendar limit.
Acute Issues: Sudden symptoms - such as new flashes, floaters, eye pain, or infections - are considered medical emergencies. These are billed to your medical insurance and do not count against or "use up" your annual routine vision benefit.
Treatment Plans: Some treatments, such as Dry Eye therapy or Binocular Vision training, involve a series of planned appointments to achieve results.
Our Commitment: Our doctors will only schedule follow-up appointments that are essential to preserving your sight. We will always communicate the reason for a follow-up and how it fits into your overall treatment plan.
* Know Before You Go: Understanding Your Costs
Because medical visits are billed differently than routine vision exams, here is what to expect regarding your out-of-pocket costs:
Co-pays: For medical follow-ups, your specialist co-pay will typically apply. This is often a different (sometimes higher) amount than your routine vision co-pay.
Deductibles: If you have a high-deductible health plan, the cost of the office visit and any specialized diagnostic testing (such as retinal imaging or visual fields) will be applied toward your annual medical deductible.
Co-insurance: Once your deductible is met, you may still be responsible for a percentage of the visit cost (co-insurance) as determined by your specific medical plan.
Routine vs. Medical: Please remember that your "free" or low-cost annual wellness exam benefit from your vision plan (like VSP or EyeMed) cannot be used for medical follow-up visits or the management of eye diseases.
Pro-Tip: We recommend checking your medical insurance card for the "Specialist" co-pay amount or logging into your insurance portal to see how much of your deductible remains before your appointment.
Glasses Rx and Contact Lens Fitting
Glasses Prescription Policy
To ensure you receive the most accurate vision correction, our glasses prescriptions are subject to the following guidelines:
Validity: Per state regulations, glasses prescriptions are valid for one year from the date of the exam. Regular eye health exams are necessary to ensure your prescription remains safe and effective.
The Refraction Fee: The refraction (the test to determine your power) is a separate part of the exam. While most vision plans cover this, many medical insurance plans do not. This fee is due at the time of service if not covered by insurance.
Re-Check Period: If you have trouble adapting to your new lenses, we offer one complimentary prescription re-check within 30 days of your original exam.
Contact Lens Fitting & Evaluation
A contact lens fitting is a specialized service performed in addition to a comprehensive eye exam. Because contact lenses are medical devices that sit directly on the eye, they require additional testing to ensure ocular health and safety.
Annual Evaluation Required: Even for long-time wearers, an annual evaluation is required to renew a contact lens prescription. This allows the doctor to check for corneal health, oxygen levels, and proper lens fit.
Fitting Fees: This fee covers the extra time, specialized measurements (like corneal topography), and any trial lenses needed to find your perfect match. Fitting fees vary based on complexity (e.g., standard, astigmatism correcting, multifocal vs. specialty scleral lenses).
Follow-Up Care: Your fitting fee includes all necessary follow-up visits related to your contact lenses for 60 days. After this period, additional office visit fees may apply.
Prescription Release: Your contact lens prescription will be finalized and released once the doctor determines the fit is successful and all follow-up appointments are completed.
Urgent Care and Workers’ Comp
Urgent Eye Care Services
Eye Care Kauai provides expert medical management for urgent conditions during standard business hours.
Conditions Treated: We address acute issues such as foreign object removal, corneal abrasions (scratches), sudden vision loss, chemical exposure, or severe eye pain.
Referrals from Urgent Care/ER: If you have already been seen at a general urgent care facility or the Emergency Room for an eye injury, we accept specialist referrals for the necessary follow-up care, surgical evaluations, or advanced diagnostic monitoring.
Advanced Diagnostics: To ensure the best outcome for trauma or sudden vision changes, our triage may include high-definition retinal imaging, OCT-retinal scan, or corneal topography to assess the full extent of the injury.
Appointment Requirements: Urgent cases are prioritized. While we recommend calling ahead, we make every effort to provide same-day care or an appointment within 24 hours.
Critical First Aid: If you have a chemical injury, immediately flush your eye with clean water or saline for at least 15 minutes before calling or traveling to the office.
After-Hours Care: For emergencies occurring on weekends or after 5:00 PM, please go to a general urgent care facility or the Wilcox Medical Center Emergency Room.
Workers' Compensation Policy
If you experience a workplace eye injury, Hawaii law protects your right to receive specialized care from a physician of your choice. Please follow these steps to ensure your treatment is fully covered:
Immediate Reporting: Notify your supervisor or employer immediately. Your employer is legally required to authorize initial medical treatment within 24 hours of the report.
The WC-1 Form: Your employer must complete an Employer’s Report of Industrial Injury/Illness (Form WC-1) and provide you with a copy.
Documentation for Check-in: To process your claim efficiently at our office, please bring:
A copy of your WC-1 Form or a signed letter from your employer.
The name and contact information of the insurance adjuster (if already assigned).
Your claim number (if available).
Coverage: Approved claims typically cover all necessary medical expenses, including specialized diagnostic testing, medications, and any required follow-up care related to the injury.
General Policies
Privacy Policy: Our office follows the guidelines established by HIPAA and HITECH regulations. Our partners in practice and in business are held to the same standards through Business Associate Agreements.
An electronic registry will be utilized to organize care and may be utilized to report data to insurance companies and public health agencies. Data generated by the practice for research purposes is confidential, and safeguards are in place to insure proper security.
The security and preservation of data are top priorities. We will abide by existing statutes which mandate timely reporting of any breach in security.
Patients receive a copy of their note, or may receive an electronic copy of their office visit, at the end of the visit. Patients are encouraged to keep a hardcopy personal health record (PHR) in safekeeping or, if online, to take precautions to ensure the privacy of their PHR.
Our practice seeks to partner with initiatives that will produce interfaces between medical offices, hospitals, labs and other healthcare facilities with HIPAA safeguards in place.
Discretion to Change Providers: A patient has the right to be seen by the provider of his/her choice and has the freedom to switch providers within our practice or to pursue healthcare outside of our practice with no interference on the part of providers or staff members. A patient who has been dismissed by the practice may not be scheduled with any provider in the practice.
Dismissal From the Practice: Dismissal from the practice does not result in exemption from payment of balances due. Referral to a collections agency is grounds for dismissal. In the event of a dismissal, we follow Hawaii State guidelines regarding formal notification and provide a limited window for emergency care while you transition to a new provider.
Medical Prescription Policies
Prescription Refill Policy: Patients are asked to call the office at least 24 hours in advance of a request for an oral or eye drop prescription refill. Prescriptions for narcotics and other controlled substances are not offered at this clinic.
Prescription Refills When Overdue for Visit: Any patient on long-term prescription medication should be seen no less than annually.
The prescription list: This is available to patients via the Patient Portal and will be kept up-to-date at the time of visit or telephone call via review with the staff or provider.
Visit Policies
LATENESS Policy: Every effort must be made to start on time. If a patient arrives more than 15 minutes late for a follow-up visit or more than 20 minutes late for a physical or pre-operative assessment, the appointment may be cancelled or rescheduled for another time. Patients whose appointments are cancelled due to lateness may be subject to the $30 no-show fee.
“NO-SHOW” Policy: If a new patient does not show up for his/her first visit, he/she will not be rescheduled with the practice. Patients who fail to come for an appointment are subject to a $30 no-show fee. Failure to appear for appointments on more than one occasion may result in dismissal from the practice.
CANCELLATION Policy: A patient who does not call to cancel an appointment more than 24 hours in advance, will be charged a $30 same-day cancellation fee.
Insurance and Payment Policies
Patients are expected to provide us with up-to-date insurance information and demographics. Current insurance cards and ID, preferably driver’s license, are required and must be verified and scanned at every visit if there are any changes. We may request Social Security numbers (SSN) for billing and identity verification purposes when insurance company requires. If a patient requests not to furnish his/her SSN, the patient should provide another form of identification. Outstanding balances due to incorrect insurance information become the patient's full responsibility.
Payment Policy: Payment of balance and co-pay and deductibles are required at the time of visit, without exception, unless arrangement has been made with the billing office one week prior to the visit. A patient who owes a balance to the practice needs to pay the balance in full before being seen by any provider.
Co-pays: Any co-payment shall be paid in full at the time of visit, as per insurance contracts and office policies; To respect your time and the doctor's schedule, we require co-pays at check-in so we can focus entirely on your care during the visit.
Deductibles: Payment in full is required for services rendered until the insurance deductible has been met. Patients are responsible for understanding their policies. Our eligibility verification process is utilized to identify deductibles through insurance carriers. We have provided resources on our website to help patients understand insurance. For local carriers such as HMSA or Kaiser, we collect based on their specific contracted allowable rates.
Collections Policy: We request prompt payment of outstanding bills. Payments can be phoned in to our office. After two statements have been sent and a courtesy call, accounts with outstanding balances will be referred to a collection agency. Patients with accounts referred to a collection agency will be dismissed from the practice with a letter mailed to the address listed in our system.
Charity Policy: Our practice offers a self-pay discount. A payment plan can be arranged prior to collections referral for outstanding balances that are hard to afford. After collections referral or with a default on a written payment plan, payment plans are no longer available.
Out-of-Network & Self-Pay Services:
For patients who are uninsured or choose to pursue care outside of their insurance network, we provide transparent billing in accordance with federal law.
Network Participation: A current list of our insurance network participation is available on our Patient Portal or upon request from our staff.
Payment Requirement: Payment in full is required at the time of service for all out-of-network visits. We will provide you with an itemized receipt (superbill) that you may submit to your insurance company for potential direct reimbursement.
Your Right to a "Good Faith Estimate":
Under the No Surprises Act, you have the right to receive a Good Faith Estimate (GFE) for the total expected cost of your non-emergency items or services.
This estimate includes related costs like medical tests, specialized imaging, and any foreseeable materials.
We will provide this estimate in writing at least one business day before your scheduled appointment. You may also request a GFE at any time before scheduling.
Note on Final Costs: While the GFE is based on information known at the time of scheduling, final costs may change if the doctor determines additional medical services are necessary during your visit.
Dispute Rights: If you receive a bill that is at least $400 more than your Good Faith Estimate, federal law allows you to dispute the bill.