Effective Dates, Available Dates and Headaches!

Cephalalgia is the medical term for headache. There is a diagnostic code in ophthalmology for headache but it is not frequently used.  It is actually uncommon for vision or eye problems to be the cause of headache, and the definition of headache from most medical sources does not even mention the eyes.  The most common underlying culprits of headache are neurological (brain, spine and nerve system), vascular (circulatory system), or muscular (stress headaches).

WGECC Staff: “Mrs. Doe, your insurance company indicates that your out-of-pocket portion for your eye surgery is $800.”

Mrs. Doe: “That must be a mistake!!  I just had my first eye surgery last month and I only paid $400.”

The headaches then start with the back and forth with the insurance company.  Our staff will go above and beyond in trying to meet the needs of our patients but often our hands are tied when negotiating with the insurance providers.  Insurance changes in the first month of a new year, and there are hundreds of providers with multiple pricing systems.  If a patient had standard Medicare last year, they may have paid $400 out of pocket as their 20% co-pay.  If that same patient opted into a new plan effective in the New Year, then the co-pay amount for the same surgery, with the same doctor, at the same center may be much more.

You may want to have some extra Tylenol on hand, because regardless of the co-pay amount, there are other insurance particulars that come into play…. for instance, if there is a delay from the “effective” date of a provider change to the “available” date of the funds, the patient may be surprised that they are required to make the payment in full!  The patient will subsequently be able to submit for reimbursement from the insurance company after the “available” date.  This means that your money is tied up until the insurance process is completed.

No matter how much we would like to, we can’t fix all of the issues with changes in insurance providers and policies. We can explain your charges to you and help you understand who to contact about your benefits.   We are here to provide the highest quality eye care possible, and then also to help as best we can with insurance headaches in January 2017 and throughout the year!