Tony Leys
Barbara Tuszynski was involved about her imaginative and prescient however assured in her insurance coverage protection when she went to a watch clinic final May.
The retiree, 70, was identified with glaucoma in her proper eye in 2019. She had a laser process to deal with it in 2022, and she or he makes use of medicated drops in each eyes to stop extra injury. She is meant to be checked often, she mentioned.
During the May appointment, Tuszynski’s optometrist examined her eyes and reassured her that the glaucoma had not worsened.
Tuszynski, who lives in central Wisconsin, had appeared up beforehand whether or not the clinic in close by Madison participated in her insurance coverage plan. The insurer’s web site listed the optometrist’s identify with a inexperienced test mark and the phrases “in-network.” She assumed that meant her coverage would cowl the appointment.
Then the invoice got here.
The Medical Procedure
An optometrist examined Tuszynski’s imaginative and prescient and took photos of her optic nerves.
The Final Bill
$340, which included $120 for imaginative and prescient testing and $100 for optic nerve imaging.
The Billing Problem: Vision Coverage vs. Medical Coverage
Tuszynski’s UnitedHealthcare Medicare Advantage plan declined to pay for her eye appointment. “The member has no out of network benefits,” the corporate’s denial letter mentioned.
Tuszynski felt like she was seeing double. How might a watch physician be in-network and out-of-network on the identical time? She mentioned she despatched the insurer a screenshot of its personal webpage exhibiting the clinic listed as in-network.
She mentioned that after she complained, UnitedHealthcare representatives defined that the attention clinic was in-network underneath her imaginative and prescient plan, so her coverage would cowl the clinic’s companies associated to glasses or contact lenses. But they mentioned the clinic was not in-network for her medical insurance coverage plan, and glaucoma therapy is taken into account a medical challenge.
Tuszynski was baffled that look after a affected person’s eyes wouldn’t be coated by imaginative and prescient insurance coverage. She mentioned she didn’t understand that insurers can have contracts with eye clinics to supply some companies however not others.
UnitedHealthcare spokesperson Meg Sergel mentioned such preparations are widespread, together with with non-Medicare insurance coverage supplied by employers or bought by people. “I looked up my eye doctor, and it’s the same thing,” she mentioned in an interview with KFF Health News.
Sergel mentioned she understood how a buyer might mistakenly assume imaginative and prescient insurance coverage would cowl all look after the eyes. She mentioned UnitedHealthcare recommends that earlier than present process therapy, sufferers ask care suppliers whether or not they’re in-network for particular companies.
Otherwise, she mentioned, to know whether or not a take a look at or therapy is roofed by imaginative and prescient insurance coverage, “you’d have to read the nitty-gritty” of a coverage.
Leaders at Steinhauer Family Eye Clinic, the place Tuszynski noticed the optometrist, declined to remark.
Casey Schwarz, senior counsel for schooling and federal coverage on the nonprofit Medicare Rights Center, mentioned such problems incessantly come up when Medicare Advantage members attempt to use their insurance coverage at eye clinics or dental places of work.
The federal authorities pays insurers to run Medicare Advantage plans for individuals who select them as a substitute of conventional Medicare. More than half of Medicare beneficiaries sign up for the private plans. Many provide routine imaginative and prescient and dental protection that isn’t included with conventional Medicare.
“We hear from people who choose these plans because of those supplemental benefits, but there is not a lot of transparency around them,” Schwarz mentioned.
The Resolution
After receiving the rejection letter, Tuszynski repeatedly contacted UnitedHealthcare to query the choice and filed an enchantment with the corporate. Then, she mentioned, she known as a Medicare hotline to complain to federal officers. She additionally wrote to KFF Health News, which requested the insurer concerning the case.
UnitedHealthcare finally agreed to cowl the invoice as if the service had been in-network. “In good faith, we made an exception,” Sergel mentioned. However, Tuszynski was warned that if she acquired medical care from the clinic once more, it might not be coated, as a result of the clinic stays out-of-network for such companies, Sergel mentioned. “It doesn’t sound like that pleased her.”
Tuszynski confirmed that she isn’t happy.
She mentioned she misplaced sleep over the dispute and felt that it shouldn’t have taken a lot effort to acquire a good consequence. “It’s just been a horrible, difficult whirlwind,” she mentioned.
The Takeaway
Schwarz mentioned regulators ought to require insurance coverage firms to obviously clarify to clients and care suppliers how totally different procedures and companies will probably be coated underneath imaginative and prescient, dental, and well being plans. “They’re tricky,” she mentioned.
In a perfect world, Schwarz mentioned, Medicare would think about issues like dental cleanings, eye checkups, and listening to aids as fundamental well being care that may be coated in the identical means as different medical care. But till that occurs, she mentioned, sufferers with any doubt ought to name their insurers beforehand to test whether or not companies will probably be coated.
Tricia Neuman, a senior vice chairman with KFF, a well being info nonprofit that features KFF Health News, famous that Medicare’s web site now includes a tool that may assist folks decide whether or not their docs take part in a Medicare Advantage plan.
“This is helpful and a step forward, but information about provider networks is not always correct,” Neuman mentioned. “Errors can come at a cost to enrollees, unless they are willing and able to take on their insurer.”
Tuszynski labored for 30 years as a secretary in hospitals and at docs’ places of work, so she’s accustomed to billing points, she mentioned. “If I can’t sort through all this, how can anybody else do it?”
She is aware of her $340 invoice was a lot smaller than the medical money owed many different folks face. But she mentioned it was a critical amount of cash to her, and she or he was glad she objected to the insurer’s rivalry that the invoice shouldn’t be coated.
“I have a strong feeling about right and wrong — and this is just wrong,” she mentioned.
For 2026, she determined to shift out of her Medicare Advantage plan. She now’s enrolled in conventional Medicare, plus a supplemental plan to assist with copays and different prices. She pays $184 a month for that plan, in contrast with paying no separate premium for her outdated Medicare Advantage plan.
Now she received’t have to fret about non-public insurers’ restricted networks of contracted care suppliers, she mentioned. Her glaucoma therapy will probably be coated on the Madison eye clinic.
However, she now not has insurance coverage protection for eyeglasses, only a low cost plan if she buys glasses from sure shops. She used her Medicare Advantage insurance coverage to purchase new glasses shortly earlier than switching. “Hopefully, those will last me a while,” she mentioned.
Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical payments. Since 2018, this collection has helped many sufferers and readers get their medical payments lowered, and it has been cited in statehouses, on the U.S. Capitol, and on the White House. Do you might have a complicated or outrageous medical invoice you need to share? Tell us about it!