No Clarity In This Process

by Dick Hall-Sizemore

Here is another example of the utter inanity of this country’s medical care system and its financing.

First, some background.  I am covered by Medicare.  I also have a Medicare supplement insurance policy issued by the Commonwealth of Virginia for retirees, administered by Anthem. (Good deal, by the way.)  I chose to include the vision and dental coverage on the Anthem policy.

Like almost everyone my age, I have developed cataracts.  A couple of years ago, an ophthalmologist told me that I qualified for cataract surgery, but that the cataracts had not progressed to the point that such surgery was highly recommended.  I chose to put it off.

Today, I went in for my annual eye exam.  As I was checking in, the staff at the Virginia Eye Institute (VEI) went to great lengths to explain that a refraction (the process of determining whether I need the prescription of my glasses changed) was not covered by insurance and that I would be responsible for the $70 if I chose refraction.  I even had to sign a form acknowledging that I had been informed of this.

During my visit, the optometry assistant (or whatever her title was) checked my vision (refraction), dilated my pupils, and conducted the pressure test for glaucoma.  Another assistant conducted a retina scan.  (There is an old scar of unknown origin on one of my retinas that the doctor is monitoring.)  The ophthalmologist then examined my eyes and informed me that the cataracts had progressed some.  He said that he could give me a prescription that would improve my vision somewhat (I have noticed some deterioration lately), but not to the level of my current prescription.  He said that, when I was ready, cataract surgery would improve my vision significantly.  I thanked him, took the prescription, and am thinking about the surgery.

During my time with the assistant and later when checking out, I asked why my insurance, with its vision option, did not cover the refraction.  Both staff members informed me that it was because I was being examined by an ophthalmologist, rather than an optometrist.  The examination by the ophthalmologist was considered a medical service, which does not include refraction.  If a VEI optometrist had conducted the refraction, it would have been covered.  I told them that did not make sense.  They agreed and said that it was not VEI’s policy, but that of the insurance company.  (If I had been a Medicaid patient or covered through Tricare or Anthem COVACARE — the insurance plan for active state employees — it would have been covered, however.)

When I got home, I called Anthem to confirm this nonsense.  Yes, I was told, refraction done by an ophthalmologist is not considered “medically necessary” and thus not covered under my policy.  However, after the claims had been processed, I could file an “out of network” claim and get a refund of $40.

In summary, I could have made two appointments back-to-back, first with the optometrist and then with the ophthalmologist. With that approach, the insurance company would have covered the refraction, while paying for two doctor’s visits, rather than one.  How irrational is that?

The biggest irony in all this is that, no matter which approach I had taken, neither the ophthalmologist nor the optometrist would have actually performed the refraction.  It would have been done by an assistant.  Because one assistant was working under an ophthalmologist, rather than an optometrist, the insurance did not cover the refraction.  Gone are the days when optometrists do refraction and check for glaucoma.  I do miss going to Benny Lambert (the late Richmond state senator, who was an optometrist) who did everything—checked my vision, checked for glaucoma, and even procured a pair of glasses on an emergency basis when I dropped mine on the marble floor of the General Assembly building and shattered a lens—all the while talking politics.