What do I owe? Routine versus medical exams
Mr. and Mrs. Smith each completed an eye exam. Upon checkout, this is what they heard:
“Mrs. Smith, you received a full eye exam with dilation and refraction with Dr. Stow. That will be $20.00, please.”
“Mr. Smith, you received a full eye exam with dilation and refraction with Dr. Stow. That will be $58.00, please.”
Mr. and Mrs. Smith received the same services from the same eye doctor. They had the same insurance provider. But they owe different amounts! Did someone make a mistake?
Not necessarily. Let’s examine the two scenarios a little more closely:
The case of Mrs. Smith: Medical Eye Exam
Mrs. Smith presented with a complaint of progressively declining vision. An exam to determine her best vision (refraction) was necessary for the doctor to evaluate the status of Mrs. Smith’s visual potential. Upon examination, the doctor noted her vision had indeed gotten worse since last year. He diagnosed Mrs. Smith with early cataracts and determined that to be the cause of her blurred vision, and said that a change of glasses would give her improvement. With a complaint and diagnosis determined in her exam, her insurance company deemed her exam to be a medical eye exam, and Mrs. Smith was only responsible for her co-pay.
The case of Mr. Smith: Routine Eye Exam
Mr. Smith presented with no complaints, only requesting an annual eye evaluation. An exam to determine his best vision (refraction) was necessary for the doctor to evaluate the status of Mr. Smith’s visual potential. Upon examination, the doctor noted Mr. Smith’s vision had actually worsened since his exam last year. Unlike his wife, Mr. Smith did not have a medical diagnosis but was told a change in his glasses prescription would improve his vision. In the absence of a complaint or medical diagnosis, Mr. Smith’s insurance company deemed his exam to be a routine eye exam and he was responsible to pay for his co-pay and the refraction.
The specifics of your insurance benefits can be confusing. Co-pays and deductibles often vary from plan to plan, and not all insurance companies are the same. Usually, eye exams are categorized as either routine or medical for insurance purposes. The reasons for and results of the examination often determine how your insurance company decides to categorize your eye exam. Different co-pays, allowances, and deductibles can all add to or subtract from the final cost of your exam.
Your insurance provider should have a customer service representative who can help you with any questions you may have.
A Special Note about Refractions:
Please bear in mind the refraction charge is rarely covered by insurance and is the patient’s responsibility to pay, but it is a necessary testing procedure to determine your best corrected vision which may determine if you need or need to update a prescription for glasses or contacts.