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The set-up
E ditor’s perspective Paul B. Freeman, O.D.
The set-up
E
verywhere we look, the “aging of America” is a media topic. (I am sure this is due, in no small part, to the first baby boomers turning 60 beginning in 2006.) Along with all of the promotional materials preparing the next older generation for the future, including recommendations about where to live, what diets to eat, and what activities to participate in to maintain a “youthful” existence, information on health care and cost protection will become more plentiful. In fact, although I am only 57, I recently received mail directed to me as a future Medicare beneficiary. It concerned health care as it relates to Medicare coverage; apparently someone feels I am closing in on Medicare age. A very personalized letter was quick to point out in bold print that “Medicare does not cover all your healthcare expenses”; hence, I should consider a Medicare preferred-provider organization. As I looked at the benefits overview, it appeared that doctors’ visits were 100% covered after a $15 copayment, and, as I looked down the list a little further, routine vision services had “100% coverage after $15 copayment for eye exam.” This was reiterated in the summary of benefits. In this packet, the definition of “routine” was not explained. Another insurance company offers a vision program that defines a routine eye examination as a “wellness checkup that fo-
cuses on assessment, preventive eye care, and determination of refractive state of the eye.” In fact, this particular insurer, in its information to beneficiaries, points out that as long as the beneficiary presents for a “routine eye examination,” that is all the doctor can bill the carrier for. If, during the examination, any pathology is discovered or determined to be the underlying cause for the chief complaint, the visit is still considered a routine eye evaluation if that is what the patient perceives the nature of the visit to be. If the provider chooses to submit that visit as a medical evaluation (based, for example, on the history, not the patient’s purported reason for the visit) along with a refraction, which is noncovered, the patient may then be responsible for a copay (under the medical coverage) as well as a fee for the noncovered refractive service. One can imagine the distress on the part of a patient who expected the examination to be fully covered under the vision plan and who is now expected to pay a fee. Incidentally, some insurers cover “medical” refractions, which may begin to alleviate some of the financial issues that a patient might have when coming in for a health-related examination and then requiring refraction. There is, however, yet another category of patients (visually impaired) who must undergo an additional type of optical evaluation for magnification purposes, and, with most insurers, this is noncovered.
Paul B. Freeman, O.D.
Unfortunately, most insurance plans suggest in a number of ways that the insured are entitled to most of their care after a simple copay, raising the issue of who is responsible for the noncovered aspects of eye care. Based on the aging process and vision-related ocular conditions that may cause either temporary or permanent decreases in vision, there will be increasingly more situations in which the medical component of the eye examination will be covered (with a copay), while the refractive component or the magnification aspect of the examination may not be covered, spawning questions about medical coverage versus “routine eye evaluations” (read refractive coverage) and magnification evaluations. And although the insured patient is fully expecting to pay only a copay, an additional responsibility for a noncovered refractive or 557
VOLUME 76 / NUMBER 10 / OCTOBER 2005
OPTOMETRY
EDITORIAL
magnification fee will undoubtedly set up a spirited discussion between office staff and patient. If, before an appointment is made, the staff attempts to avoid this interchange by explaining over the phone the complexities of what may or may not be covered, chances are a lengthy dialogue will ensue. Perhaps the patient will look for another provider who may simply forgo the refractive component of a medical eye examination, or waive the fee for this noncovered service, or not even entertain the magnification aspect of an evaluation for someone who could be helped to see through those additional procedures. Whereas this will surely become more of a problem for eye care providers as insurers compete for this burgeoning population of seniors, it would seem that educating carriers to understand the various mixes of
covered and noncovered services (which might be specialty specific) could go a long way in supporting providers and their office staffs, who will be faced with this often disagreeable interchange. Helping beneficiaries understand these scenarios as well will help them also understand these financial situations and, hopefully, avoid the feelings engendered by provider and beneficiary entering into an adversarial relationship. Patients assume that providers are always adequately compensated for their services (with patients being insulated from the actual cost of care); otherwise why would the doctor accept the insurance or participate in the plan? This ultimately puts the provider, not the insurer, in a bad light, something no health care provider wants to have interfering with good care.
Ultimately, most patients go to an eye doctor because they want to see well. And, thankfully, for most patients (even those with medical conditions), the solution is a good refraction, with prescribed glasses or contact lenses. In a medical eye evaluation this is often a noncovered procedure. We all can think of examples in which we have prescribed lenses for someone for whom it was a lifechanging experience, including the Midwest optometrist who prescribed for a young hyperopic future president: for Harry Truman “all at once the world was transformed for him, as if by magic.”1 Although I am sure this service was paid for out-ofpocket, I am also quite sure it was well worth it. Enough said.
Reference 1. McCullough D. Truman. New York: Simon and Schuster, 1992:41.
558 OPTOMETRY
VOLUME 76 / NUMBER 10 / OCTOBER 2005
The set-up
E
verywhere we look, the “aging of America” is a media topic. (I am sure this is due, in no small part, to the first baby boomers turning 60 beginning in 2006.) Along with all of the promotional materials preparing the next older generation for the future, including recommendations about where to live, what diets to eat, and what activities to participate in to maintain a “youthful” existence, information on health care and cost protection will become more plentiful. In fact, although I am only 57, I recently received mail directed to me as a future Medicare beneficiary. It concerned health care as it relates to Medicare coverage; apparently someone feels I am closing in on Medicare age. A very personalized letter was quick to point out in bold print that “Medicare does not cover all your healthcare expenses”; hence, I should consider a Medicare preferred-provider organization. As I looked at the benefits overview, it appeared that doctors’ visits were 100% covered after a $15 copayment, and, as I looked down the list a little further, routine vision services had “100% coverage after $15 copayment for eye exam.” This was reiterated in the summary of benefits. In this packet, the definition of “routine” was not explained. Another insurance company offers a vision program that defines a routine eye examination as a “wellness checkup that fo-
cuses on assessment, preventive eye care, and determination of refractive state of the eye.” In fact, this particular insurer, in its information to beneficiaries, points out that as long as the beneficiary presents for a “routine eye examination,” that is all the doctor can bill the carrier for. If, during the examination, any pathology is discovered or determined to be the underlying cause for the chief complaint, the visit is still considered a routine eye evaluation if that is what the patient perceives the nature of the visit to be. If the provider chooses to submit that visit as a medical evaluation (based, for example, on the history, not the patient’s purported reason for the visit) along with a refraction, which is noncovered, the patient may then be responsible for a copay (under the medical coverage) as well as a fee for the noncovered refractive service. One can imagine the distress on the part of a patient who expected the examination to be fully covered under the vision plan and who is now expected to pay a fee. Incidentally, some insurers cover “medical” refractions, which may begin to alleviate some of the financial issues that a patient might have when coming in for a health-related examination and then requiring refraction. There is, however, yet another category of patients (visually impaired) who must undergo an additional type of optical evaluation for magnification purposes, and, with most insurers, this is noncovered.
Paul B. Freeman, O.D.
Unfortunately, most insurance plans suggest in a number of ways that the insured are entitled to most of their care after a simple copay, raising the issue of who is responsible for the noncovered aspects of eye care. Based on the aging process and vision-related ocular conditions that may cause either temporary or permanent decreases in vision, there will be increasingly more situations in which the medical component of the eye examination will be covered (with a copay), while the refractive component or the magnification aspect of the examination may not be covered, spawning questions about medical coverage versus “routine eye evaluations” (read refractive coverage) and magnification evaluations. And although the insured patient is fully expecting to pay only a copay, an additional responsibility for a noncovered refractive or 557
VOLUME 76 / NUMBER 10 / OCTOBER 2005
OPTOMETRY
EDITORIAL
magnification fee will undoubtedly set up a spirited discussion between office staff and patient. If, before an appointment is made, the staff attempts to avoid this interchange by explaining over the phone the complexities of what may or may not be covered, chances are a lengthy dialogue will ensue. Perhaps the patient will look for another provider who may simply forgo the refractive component of a medical eye examination, or waive the fee for this noncovered service, or not even entertain the magnification aspect of an evaluation for someone who could be helped to see through those additional procedures. Whereas this will surely become more of a problem for eye care providers as insurers compete for this burgeoning population of seniors, it would seem that educating carriers to understand the various mixes of
covered and noncovered services (which might be specialty specific) could go a long way in supporting providers and their office staffs, who will be faced with this often disagreeable interchange. Helping beneficiaries understand these scenarios as well will help them also understand these financial situations and, hopefully, avoid the feelings engendered by provider and beneficiary entering into an adversarial relationship. Patients assume that providers are always adequately compensated for their services (with patients being insulated from the actual cost of care); otherwise why would the doctor accept the insurance or participate in the plan? This ultimately puts the provider, not the insurer, in a bad light, something no health care provider wants to have interfering with good care.
Ultimately, most patients go to an eye doctor because they want to see well. And, thankfully, for most patients (even those with medical conditions), the solution is a good refraction, with prescribed glasses or contact lenses. In a medical eye evaluation this is often a noncovered procedure. We all can think of examples in which we have prescribed lenses for someone for whom it was a lifechanging experience, including the Midwest optometrist who prescribed for a young hyperopic future president: for Harry Truman “all at once the world was transformed for him, as if by magic.”1 Although I am sure this service was paid for out-ofpocket, I am also quite sure it was well worth it. Enough said.
Reference 1. McCullough D. Truman. New York: Simon and Schuster, 1992:41.
558 OPTOMETRY
VOLUME 76 / NUMBER 10 / OCTOBER 2005