Barbara Tuszynski was concerned about her vision but confident in her insurance coverage when she went to an eye clinic last May.<\/p>\n
The retiree, 70, was diagnosed with glaucoma in her right eye in 2019. She had a laser procedure to treat it in 2022, and she uses medicated drops in both eyes to prevent more damage. She is supposed to be checked regularly, she said.<\/p>\n
During the May appointment, Tuszynski\u2019s optometrist examined her eyes and reassured her that the glaucoma had not worsened.<\/p>\n
Tuszynski, who lives in central Wisconsin, had looked up beforehand whether the clinic in nearby Madison participated in her insurance plan. The insurer\u2019s website listed the optometrist\u2019s name with a green check mark and the words \u201cin-network.\u201d She assumed that meant her policy would cover the appointment.<\/p>\n
Then the bill came.<\/p>\n
The Medical Procedure<\/strong><\/p>\n An optometrist tested Tuszynski\u2019s vision and took pictures of her optic nerves.<\/p>\n The Final Bill<\/strong><\/p>\n $340, which included $120 for vision testing and $100 for optic nerve imaging.<\/p>\n The Billing Problem: Vision Coverage vs. Medical Coverage<\/strong><\/p>\n Tuszynski\u2019s UnitedHealthcare Medicare Advantage plan declined to pay for her eye appointment. \u201cThe member has no out of network benefits,\u201d the company\u2019s denial letter said.<\/p>\n Tuszynski felt like she was seeing double. How could an eye doctor be in-network and out-of-network at the same time? She said she sent the insurer a screenshot of its own webpage showing the clinic listed as in-network.<\/p>\n She said that after she complained, UnitedHealthcare representatives explained that the eye clinic was in-network under her vision plan, so her policy would cover the clinic\u2019s services related to glasses or contact lenses. But they said the clinic was not in-network for her medical insurance plan, and glaucoma treatment is considered a medical issue.<\/p>\n Tuszynski was baffled that care for a patient\u2019s eyes would not be covered by vision insurance. She said she didn\u2019t realize that insurers can have contracts with eye clinics to provide some services but not others.<\/p>\n UnitedHealthcare spokesperson Meg Sergel said such arrangements are common, including with non-Medicare insurance provided by employers or purchased by individuals. \u201cI looked up my eye doctor, and it\u2019s the same thing,\u201d she said in an interview with KFF Health News.<\/p>\n Sergel said she understood how a customer could mistakenly think vision insurance would cover all care for the eyes. She said UnitedHealthcare recommends that before undergoing treatment, patients ask care providers whether they are in-network for specific services.<\/p>\n Otherwise, she said, to know whether a test or treatment is covered by vision insurance, \u201cyou\u2019d have to read the nitty-gritty\u201d of a policy.<\/p>\n Leaders at Steinhauer Family Eye Clinic, where Tuszynski saw the optometrist, declined to comment.<\/p>\n Casey Schwarz, senior counsel for education and federal policy at the nonprofit Medicare Rights Center<\/a>, said such complications frequently come up when Medicare Advantage members try to use their insurance at eye clinics or dental offices.<\/p>\n The federal government pays insurers to run Medicare Advantage plans for people who choose them instead of traditional Medicare. More than half of Medicare beneficiaries sign up for the private plans<\/a>. Many offer routine vision and dental coverage that isn\u2019t included with traditional Medicare.<\/p>\n \u201cWe hear from people who choose these plans because of those supplemental benefits, but there is not a lot of transparency around them,\u201d Schwarz said.<\/p>\n \n\t\tSubscribe to KFF Health News’ free weekly newsletter, “The Week in Brief.”\t<\/p>\n<\/div>\n The Resolution<\/strong><\/p>\n After receiving the rejection letter, Tuszynski repeatedly contacted UnitedHealthcare to question the decision and filed an appeal with the company. Then, she said, she called a Medicare hotline<\/a> to complain to federal officials. She also wrote to KFF Health News, which asked the insurer about the case.<\/p>\n UnitedHealthcare eventually agreed to cover the bill as if the service had been in-network. \u201cIn good faith, we made an exception,\u201d Sergel said. However, Tuszynski was warned that if she received medical care from the clinic again, it would not be covered, because the clinic remains out-of-network for such services, Sergel said. \u201cIt doesn\u2019t sound like that pleased her.\u201d<\/p>\n Tuszynski confirmed that she is not pleased.<\/p>\n She said she lost sleep over the dispute and felt that it shouldn\u2019t have taken so much effort to obtain a fair outcome. \u201cIt\u2019s just been a horrible, difficult whirlwind,\u201d she said.<\/p>\n The Takeaway<\/strong><\/p>\n Schwarz said regulators should require insurance companies to clearly explain to customers and care providers how different procedures and services will be covered under vision, dental, and health plans. \u201cThey\u2019re tricky,\u201d she said.<\/p>\n In an ideal world, Schwarz said, Medicare would consider things like dental cleanings, eye checkups, and hearing aids as basic health care that would be covered in the same way as other medical care. But until that happens, she said, patients with any doubt should call their insurers beforehand to check whether services will be covered.<\/p>\n Tricia Neuman, a senior vice president with KFF, a health information nonprofit that includes KFF Health News, noted that Medicare\u2019s website now includes a tool<\/a> that can help people determine whether their doctors participate in a Medicare Advantage plan.<\/p>\n \u201cThis is helpful and a step forward, but information about provider networks is not always correct,\u201d Neuman said. \u201cErrors can come at a cost to enrollees, unless they are willing and able to take on their insurer.\u201d<\/p>\n Tuszynski worked for 30 years as a secretary in hospitals and at doctors\u2019 offices, so she\u2019s familiar with billing issues, she said. \u201cIf I can\u2019t sort through all this, how can anybody else do it?\u201d<\/p>\n She knows her $340 bill was much smaller than the medical debts many other people face. But she said it was a serious amount of money to her, and she was glad she objected to the insurer\u2019s contention that the bill shouldn\u2019t be covered.<\/p>\n \u201cI have a strong feeling about right and wrong \u2014 and this is just wrong,\u201d she said.<\/p>\n For 2026, she decided to shift out of her Medicare Advantage plan. She now is enrolled in traditional Medicare, plus a supplemental plan to help with copays and other costs. She pays $184 a month for that plan, compared with paying no separate premium for her old Medicare Advantage plan.<\/p>\n Now she won\u2019t have to worry about private insurers\u2019 limited networks of contracted care providers, she said. Her glaucoma treatment will be covered at the Madison eye clinic.<\/p>\n However, she no longer has insurance coverage for eyeglasses, just a discount plan if she buys glasses from certain stores. She used her Medicare Advantage insurance to buy new glasses shortly before switching. \u201cHopefully, those will last me a while,\u201d she said.<\/p>\n Bill of the Month is a crowdsourced investigation by\u00a0KFF Health News<\/a>\u00a0and\u00a0The Washington Post\u2019s Well+Being<\/a>\u00a0that dissects and explains medical bills.\u00a0Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share?\u00a0Tell us about it<\/a>!<\/em><\/p>\n<\/p><\/div>\n\n\t\t
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