My plan has a no-cost vision exam, why am I still getting a bill?

We recently received a call from one of our long-term clients who was very concerned about a bill from his eye doctor. 

He was enrolled in an Advantage plan which includes a no-cost eye exam as part of his benefits (as most do).  

He was extremely surprised when he received a bill for a specialist copay instead. 

The question here is: did my eye doctor make a billing mistake?

Medicare rules are very specific when it comes to vision.  If a visit to your eye doctor is for a routine eye exam (refractory exam), then it’s typically not covered by traditional Medicare.  If your Supplement or Advantage plan covers an eye exam, then your additional coverage will pay for the service.  However, when you go to your eye doctor for a reason Medicare categorizes as medical (glaucoma, etc.), then Medicare does cover the services the same as if you were to see any other specialist.

What we’re seeing is that many eye doctors are billing not only for the routine eye exam, but they’re also billing for an additional office visit on top of the exam.  This certainly results in additional revenue for the office but will also result in a specialist copay for the patient.

We see this as a grey zone in billing but unfortunately, this is common practice.  Many of the insurance companies have allowed it to happen.

So next time when you go to the eye doctor, it’s always good to confirm whether you’ll need to pay for an extra copay as an office visit for your routine eye exam.