Avoiding unnecessary medical procedures that aren’t covered by insurance

by Karen on January 17, 2009

A few months ago, I wrote about a surprise bill I received from my dentist. Even though my insurance covers X-rays, preventative exams & two cleanings a year, I received a bill for an extra X-ray that wasn’t covered. I decided to keep a closer watch on the procedures being performed on me in future visits and ask more questions about my insurance coverage.

Today I had an eye exam. Before the exam, the optometry tech asked if I’d like to have my retina scanned and photographed. The procedure would allow them to see underlying problems with my eyes. I asked if the procedure was necessary for someone my age, and she acknowledged that it probably wasn’t completely necessary, but that they recommend it for patients of all ages.

I was upfront with her. “I’m here for an eye exam and a contact lens fitting,” I said politely. “Can you tell me what my insurance will cover, and please let me know if you plan to perform any procedures that won’t be covered?”

The point isn’t to refuse all treatment that isn’t covered. I just want to know what is and isn’t covered so I can make informed choices about my health care.

I knew that my eye exam was covered, but I wasn’t sure what exactly that included. I also had a feeling that anything related to contact lenses would not be covered.

She looked up my information and told me what I already knew — the eye exam was covered completely, but the “contact lens fitting,” which is necessary to get new contacts, would have to come out of my pocket. That’s ok, because my employer offers an HRA, so I will be reimbursed.

She was surprised to discover that the retina scan was actually covered 100% if I elected to do it. Well, ok. If it’s covered, why not?

I’m glad I asked. If it wasn’t covered, I wouldn’t have wanted to be billed for it. I’m also glad I didn’t refuse the procedure without knowing. I want to take full advantage of my health insurance benefits.

Though the total cost of the exam was over $300, I paid $63. The contact lens fitting was $75, but I’m also a member of a vision discount plan in addition to my insurance, so I received a small discount.

I’m a little miffed about the high cost of the “contact lens fitting.” Basically, all it entailed was the doctor asking me if I’m comfortable with my current lenses, poking a new set of lenses into my eyes, and giving me a sales pitch about the new, more expensive brand. I have another appointment in two weeks, at which point he’ll ask if I like the new brand, give me another sales pitch, and finally write my contact lens prescription. It just seems like $75 is a little ridiculous for that. Whatever, though. I guess that’s the price I pay to wear contacts.

Consider being an active participant in your medical care. Always ask for more information about procedures and insurance coverage. It’s sad but true that many providers will push unnecessary services onto patients despite the fact that they aren’t covered by insurance.

Never refuse a necessary procedure just because you don’t want to pay out of pocket. Your health should always come first. Just be sure that you’re not paying out of pocket for a procedure that you don’t need.

photo by chrismar

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{ 7 comments }

1 Kacie January 17, 2009 at 8:43 pm

I think “contact lens fitting” is a total scam. Maybe there’s more to it than they’re letting on, but it really seems like the dr. just asks if they feel ok.

2 Andrea January 17, 2009 at 9:00 pm

I definitely agree that it’s important to be a good consumer of healthcare and to understand what your insurance covers. However, I would add that being a good consumer of healthcare includes being responsible with all of your healthcare choices, even the ones the insurance company is paying for. Just because something is covered, doesn’t mean you should do it if it isn’t necessary. High medical costs incurred by insurance companies ultimately leads to higher premiums and affects us all. Just my two cents.

3 Funny about Money January 17, 2009 at 10:31 pm

Be aware that some of these people don’t know what’s covered. It’s commonplace for doctors’ front office personnel to tell you the practice is in your insurance company’s network, when surprise! It’s not. I’m still going around and around with one of my now-very-former doctors, whose office, after trying to charge me $80 for a flu shot that my insurance refused to cover, is trying to charge me for an insurance copay even though they lied … uhm … were mistaken in saying they were in network.

BTW, Kacie’s got something. My contact lens provider produces perfectly fine contact lenses when handed a prescription from an optometrist or an ophthamologist. No “fitting” is involved. You can get an eye exam & prescription from Costco for $50.

I believe you can order contact lenses online, with a prescription.

Funny about Money’s last blog post..Win 6 months of the W. St. J.

4 Karen January 18, 2009 at 10:29 am

Thanks for the advice! I definitely did some research before showing up at the office. That’s how I knew that the exam was covered, but the contacts wouldn’t be.

I don’t plan to buy my contacts at the office, because I can get a better deal at Costco. But Costco isn’t in my insurance network, so I opted to get my exam done with a doctor who was. Unfortunately, I can’t get my prescription without the fitting.

Does Costco charge for a fitting if you get your exam and prescription from them? If not, then I’ll pay the $50 in the future. Even paying for the exam out of network is a better deal than being covered for the exam but paying $63 for the fitting!

5 Jill January 18, 2009 at 11:08 pm

I am in agreement on this whole contact lens fitting. It is quite a bit of crap. I too had an eye exam on saturday, and was charged for the fitting, but I wasn’t even given a new pair of lenses to “fit.” Luckily my fitting was less expensive–$30 at Pearle Vision. I think I had the retina scan procedure you’re describing, about a year ago (the photo of the back of your eye basically?). I opted out of it this time because it was pretty pricey.

6 MickeyButler October 14, 2010 at 6:23 pm

I recently went for an eye exam to get a new eyeglass prescription. The opthomologist, who was new to me, took a photo of my eye, but didn’t discuss it. I now find it’s only partially covered. My routine exam to get a prescription was billed at $500. Any suggestions as to how to dispute the copay I was asked for which came to $64.00

7 Karen October 14, 2010 at 8:22 pm

Mickey – If you can convince your insurance company to waive it, I’d love to know how you did it. In my experience, if you call to dispute, the insurance company will likely refer you back to the provider, who will insist that you agreed to the procedure and the charge will stand. If you didn’t consent to the procedure, you might have some luck disputing it. Unfortunately, though, since there’s no governing body to turn to, if the insurance company and doctor’s office won’t reverse the charge, then you’re likely out of luck.

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