Posted and filed under Fraud, Healthcare.

Are you being used by your doctor?

Do you ever go to your optometrist for a routine eye exam and unknowingly leave with a medical condition? Were you asked for your medical insurance card at your visit? Why is that?

Routine eye exams are covered by your vision plan. Most people go for an eye exam every two years when they wear glasses or contacts to correct their vision. Your vision provider (optometrist) will submit a claim (bill) to your insurance company for your exam and determine your refractive state (eyeglass or contact prescription). The claim will have your diagnosis code listed as either myopia (nearsightedness), hyperopia (farsightedness), or both. The insurance company will pay the vision provider around $50.

Medical insurance does not pay for determining your refractive state; although it does pay for an eye exam…when you have a medical condition – and it pays up to three times as much!

Some optometrists will diagnose you with a medical condition in order to bill your medical insurance for your eye exam instead of your vision plan in order to increase his/her payment. They may also do unnecessary testing to increase the payment even further. Some even bill both your vision and medical plans for the same examination with different diagnosis codes.

How can you be sure this does not happen to you?

Always review the explanation of benefits (EOB) that your insurance company provides. This will give you the detail of diagnosis and procedure codes that your optometrist billed to the insurance company. If it doesn’t look right, call your optometrist to clarify. If you’ve never discussed your eyes being itchy with your vision provider, which resulted in you being diagnosed with chronic allergic conjunctivitis, your vision provider may have included you in a fraudulent billing scheme to increase reimbursement.  You should report this to your insurance company so they can investigate further.