Charges on Your Eye Exam — Why Some Doctors Ask for More

Health Letter, March 2016

For many people, an eye exam is a trip to the eye doctor (either an ophthalmologist or an optometrist) for a prescription for eyeglasses or contact lenses.

Yet after the visit, many patients find that they are charged one fee for the exam and a separate fee for refraction.[1] Refraction — the part of the exam when patients are asked to look through different lenses while reading a series of small letters and then asked which lens is better — is the test used to determine what prescription is needed for glasses or contact lenses.

Eye doctors sometimes will tell patients that refraction is an essential part of the eye exam, but it generally is not covered by health insurance. Why would an essential service be so widely disregarded by insurers, and why do some doctors not charge this fee?

Healthy eyes versus seeing better

The answer to these questions comes in part from a somewhat arbitrary distinction that health insurance companies draw: keeping eyes healthy versus improving vision through use of glasses or contacts.

Under the Medicare statute, doctor’s office coverage under Medicare Part B is not supposed to cover eyeglasses or refractions.[2] Most private health insurance companies have followed Medicare’s example, forcing patients to either pay these expenses out of pocket or buy vision insurance.[3]

Medicare and other health insurers do, however, cover eye exams to test for eye disease.[4],[5] Under Medicare, these exams include testing for glaucoma, macular degeneration and diabetic retinopathy.

Eye doctors have found that they can make more money by billing Medicare or other health insurers for an eye exam to test for disease than relying on reimbursements from vision insurance, which tend to be lower than health insurance payments.[6] But because Medicare and most private health insurers do not cover refraction, an eye doctor who performs this service during the exam often will issue two separate bills: one for the eye exam and one for the refraction.[7]

Some eye doctors choose not to charge separately for refraction, meaning patients only have to pay for the co-payment on the eye exam, and receive no additional bill.[8] But Medicare and other insurance companies technically prohibit this practice: A doctor who fails to charge a refraction fee may be accused of overcharging for the exam to cover the cost of the refraction. If caught by the insurance company, the doctor could be asked to pay back to the insurer the cost of all the unbilled refraction fees.[9]

Another reason doctors charge separately for refraction is that the practice is profitable. As one provider stated candidly in a trade journal targeted at eye doctors, “[R]efraction is a service that is valuable and people will pay for it. If it’s a non-covered service and the patient must pay out of pocket for it … all the better!”[10]

What can patients do?

Charging separately for refraction is increasingly becoming a standard practice among eye doctors. Unfortunately, the practice of charging separately for refraction results in higher out-of-pocket expenses for patients, particularly those who lack adequate health or vision insurance.

For patients with good vision who do not require glasses or contacts, it may be possible to avoid the refraction fee by simply declining the service. A doctor should tell you prior to the exam whether he or she charges separately for refraction. Often, this is done through a standard notice that patients are required to sign when they arrive at the office.[12] Such notices sometimes will include strong language pressuring patients to undergo refraction, stating that the procedure is needed to assess the health and function of the eyes.[13]

While some eye doctors may truly believe that refraction is the best way to detect vision loss, a standard eye exam should include several other tests specifically designed to detect vision problems and eye disease.[14] Most patients are already familiar with simple tests for vision loss, which involve reading letters on an eye chart. A common test to screen for macular degeneration involves asking patients to look at a small grid and report any faded, broken or distorted lines.[15] Tests for glaucoma sometimes involve assessing the inner pressure of the eye by using a machine that delivers a tiny puff of air. An eye doctor also may dilate your eye in order to look for damage occurring in the inner parts of your eye, such as the retina and optic nerve.

Given the availability of these tests specifically designed to measure vision loss and diagnose eye disease, patients who can see well without contacts or glasses should feel comfortable politely declining refraction as an unnecessary service, particularly if it requires an extra fee.

How Often Should You Have an Eye Exam? [16]

According to the American Academy of Ophthalmology, routine eye exams are not needed for people under the age of 40 who don’t have diabetes are not at high risk of glaucoma and haven’t had any symptoms of eye disease. For those ages 40 to 54, the group recommends having an exam every two to four years. For individuals 55 to 64, this period should be shortened to one to three years, and those beyond age 65 should have an exam every one to two years.

For individuals at higher risk for glaucoma, including African-Americans and Latinos, exams should be more frequent: every two to four years for those under age 40, every one to three years for those aged 40 to 54, and every one to two years for those aged 55 to 64.

Patient with type 1 diabetes should be examined by an ophthalmologist five years after disease onset and at least yearly thereafter. People with type 2 diabetes should be examined at the time of diagnosis and at least yearly thereafter.

These regular screenings should be sufficient to detect major eye problems, regardless of whether refraction is also included as part of the exam.


References

[1] Young M. Seeing red over the refraction charge. EyeWorld. November 2007. www.eyeworld.org/article.php?sid=4126. Accessed February 18, 2016.

[2] Centers for Medicare and Medicaid Services. Your Medicare benefits. www.medicare.gov/Pubs/pdf/10116.pdf. Accessed February 18, 2016.

[3] Bedinghaus T. Medicare Vision Benefits. December 16, 2014. http://vision.about.com/od/commonvisionproblems/a/Medicare_Vision.htm. Accessed February 18, 2016.

[4] Network rapid update: Clarification of vision benefits under health care reform. Anthem. March 15, 2012. https://www.anthem.com/provider/noapplication/f1/s0/t0/pw_e181260.pdf?refer=ahpprovider&state=oh. Accessed February 18, 2016.

[5] Centers for Medicare and Medicaid Services. Your Medicare benefits. https://www.medicare.gov/Pubs/pdf/10116.pdf. Accessed February 18, 2016.

[6] Dean DC. Bill your patients’ medical insurance (the right way). Review of Optometry. May 2, 2006. www.reviewofoptometry.com/content/d/news_review/c/17201/dnnprintmode/true/?skinsrc=%5Bl%5Dskins/ro2009/pageprint&containersrc=%5Bl%5Dcontainers/ro2009/simple. Accessed February 18, 2016.

[7] Gailmard NB. Management tip of the week: Should you charge for refraction? Optometric Management. August 19, 2009. http://www.optometricmanagement.com/mtotw/tip_new.asp?tip=393. Accessed February 18, 2016.

[8] Ibid.

[9] Ibid.

[10] Ibid.

[11] Flaum Eye Institute Department of Opthalmology. Why do I have to pay for refraction? www.urmc.rochester.edu/medialibraries/urmcmedia/eye-institute/patient-services-information/patient-informationhttps://www.urmc.rochester.edu/medialibraries/urmcmedia/eye-institute/patient-services-information/patient-information/documents/payingforrefractionfaqs_final7.pdf. Accessed February 18, 2016.

[12] Young M. Seeing red over the refraction charge. EyeWorld. November 2007. www.eyeworld.org/article.php?sid=4126. Accessed February 18, 2016.

[13] Flaum Eye Institute Department of Opthalmology. Why do I have to pay for refraction? www.urmc.rochester.edu/medialibraries/urmcmedia/eye-institute/patient-services-information/patient-informationhttps://www.urmc.rochester.edu/medialibraries/urmcmedia/eye-institute/patient-services-information/patient-information/documents/payingforrefractionfaqs_final7.pdf. Accessed February 18, 2016.

[14] Gailmard NB. Management tip of the week: Should you charge for refraction? Optometric Management. August 19, 2009. http://www.optometricmanagement.com/mtotw/tip_new.asp?tip=393. Accessed February 18, 2016.

[15] Mayo Clinic. Dry macular degeneration: diagnosis. December 4, 2015. www.mayoclinic.org/diseases-conditions/dry-macular-degeneration/diagnosis-treatment/diagnosis/dxc-20165013. Accessed February 18, 2016.

[16] American Academy of Ophthalmology. Frequency of Ocular Examinations – 2015. March 2015. www.aao.org/clinical-statement/frequency-of-ocular-examinations–november-2009. Accessed February 18, 2016.