So uh, who pays for your eye-related medical care?
November 2, 2021 2:51 PM   Subscribe

The other day I went to urgent care and was given a referral to an ophthalmologist at a hospital, who told me that my sudden weird vision was an ocular migraine. Ok all good! Except my insurance didn't pay for it...and neither will my vision insurance? Who pays for this stuff? (in the US)

If I have to pay this bill in its entirety it will be annoying, but fine. But now I'm sort of freaked out! My mom (who is on medicare) had a retinal tear, and my understanding is that was very expensive but medicare covered the treatment. What if that happens to me??

I have BCBS, a nice fancy PPO, but when I called they were immediately like "nope no way we do not pay for anything about eyes ever", even though this was clearly a medical appointment and not like, a Lens Crafters eye exam. But my vision insurance ONLY covers a Lens Crafters eye exam, basically, and the ophthalmologist (being a doctor) does not take my weird Lens Crafters-caliber vision insurance.

Is it normal for medical insurance to just not cover anything about eyes, regardless of what it is? And if I did ever have an eye-related emergency, should I just expect to foot a thousands-of-dollars bill myself?

OR: Is there some magical keyword I can say to the insurance to make them pay for the exam? Sometimes there is so I feel like it's worth asking.

(I know all plans are different and you don't know the details of my plan, but neither did the guy on the phone who literally works for them so as far as I can tell you are just as qualified to answer my questions)
posted by goodbyewaffles to Health & Fitness (24 answers total) 2 users marked this as a favorite
Best answer: There should be a plan document that lists exclusions. My husband's old crappy student insurance basically said "we don't cover anything related to the sinuses" which really sucked when he couldn't get a polypectomy and his sinus tumor went undiagnosed for a year 🤷

But the plan document needs to be read very carefully. My husband's slightly better insurance always denied his cancer-related opthalmology appointments even though they were not actually excluded, only eye exams of healthy eyes were excluded. Every year we had to appeal and every year they paid the bill on appeal while maintaining that eye exams were not covered.
posted by muddgirl at 2:59 PM on November 2, 2021 [1 favorite]

An ocular migraine, it seems to me, is a neurological problem, not an eye problem. So, urgent care sent you to wrong kind of specialist. Do you have a primary care doc? Is she or he part of the same network as the urgent care and the ophthalmologist? If so, maybe someone in their office can help you get this straightened out and give you a referral to a neurologist. Insurance is acting like this is a vision problem, not a medical/neurological problem. Your mother's torn retina was an injury to her eye, not a vision problem, I guess. US insurance sucks!
posted by mareli at 3:02 PM on November 2, 2021 [5 favorites]

You should be able to review your plan's policy document to see what is covered and what isn't. It's quite common for health insurance to exclude eye exams and corrective lenses; I don't think I've heard of many cases where treatment for actual diseases involving the eyes are excluded. At any rate, ocular migraine is a brain, not an eye, condition, and it's weird to me that they're even treating it as an eye examination.
posted by praemunire at 3:05 PM on November 2, 2021 [1 favorite]

Response by poster: So the reason I was referred to an ophthalmologist is that my eyes went totally blurry and I couldn't really see for an hour, and the urgent care doctor didn't know why and wanted to make sure it wasn't something eye-related. The ophthalmologist seemed to think it was pretty common for his office to be the first stop for someone who'd never had an ocular migraine before.
posted by goodbyewaffles at 3:07 PM on November 2, 2021

Response by poster: (also this is an idiot question but where would I even find the plan documents?? Are they online somewhere or is this something they snail-mailed me in 2011? My "blue access for members" account does not seem to have anything)
posted by goodbyewaffles at 3:09 PM on November 2, 2021

I don't have BCBS but it would be really unusual in this day and age not to have the plan documents all online.
posted by praemunire at 3:12 PM on November 2, 2021 [1 favorite]

Best answer: My insurance company denies ophthalmology claims all the time even though they're covered because it's eyes. It sucks, but you might have to appeal it.
posted by Mavri at 3:20 PM on November 2, 2021 [2 favorites]

I just got switched to BCBS this year and the online situation is really different from my old insurance's site, and not intuitive--not an idiot question!

To find your documents, you'll have to go to your local BCBS site (they have a bunch of different ones, and yours might not be your home state--for example, mine is based in the state where my company is headquartered, even though I don't live or get medical care there).

Go to the Access My Benefits page and then put in the prefix for your ID number in the little box on the right, and it should tell you which is your local affiliate. Then you log in on THEIR site to get your full summary of benefits. There should be a specific phone app for your local BCBS, too.
posted by assenav at 3:24 PM on November 2, 2021 [7 favorites]

Best answer: I have yet to be successful at finding those docs via Blue Access. I am insured through my employer and have to go through their benefits portal to get that.
posted by sm1tten at 3:27 PM on November 2, 2021 [1 favorite]

Best answer: Is it normal for medical insurance to just not cover anything about eyes, regardless of what it is? And if I did ever have an eye-related emergency, should I just expect to foot a thousands-of-dollars bill myself?

I was referred to an hospital ophthalmologist by an optometrist at Pearle Vision due to an occlusion. Blue Cross covered me as soon as I went to the hospital/clinic including the tests ordered by the ophthalmologist. However, my policy does cover a single eye exam each year, but specifies nothing more. I would push hard on BCBS to get this covered because you were referred there by a medical professional and the results are not limited to your eyes.

If you get your insurance through your employer (or someone else's employer), you may have some recourse there. Your benefits people should have a hotline for you to use. You may also want to see if your state attorney general's office can help.
posted by soelo at 3:37 PM on November 2, 2021 [2 favorites]

Once you find the plan documents, assuming they do cover medical eye issues, I would appeal. It's very likely that they just see ophthalmologist and automatically put in the "no" pile, without looking into the details of the symptoms and treatment. FWIW I have a BCBS PPO plan and they do cover some visits related to dry eye, but not the usual contacts exam.
posted by tuesdayschild at 3:38 PM on November 2, 2021

Also, the ophthalmologist's office may be a good source for info on how to get this covered. They have someone whose main job is billing, so they probably see this a lot. If you get nowhere and do have to pay, I would ask the office for a discount as an uninsured person.
posted by soelo at 3:40 PM on November 2, 2021 [2 favorites]

Best answer: Appeal, appeal, appeal.

Dollars to donuts the person (or more likely, algorithm) doing the initial denial here just saw "eyes" and put it in the "no" bucket although as mareli says, this is a neurological diagnosis.

You might need to talk to the hospital to make sure it was submitted correctly as a medical rather than a vision diagnosis. I imagine they did, though, because otherwise the ophthalmologist would never get paid. Nine times out of 10, these knee-jerk denials are immediately reversed on appeal, once an actual human lays their hands on it.
posted by basalganglia at 3:41 PM on November 2, 2021 [7 favorites]

In my recent experience of insurance appeals (for a baby who needed an air ambulance to get to a NICU, so not eyes), the first time we asked for an appeal, nothing changed. The second time, I submitted all the medical records, a letter from the doctor who ordered the care and a letter from myself explaining the situation. That worked, 2.5 months after they said the appeal would be answered.
posted by carolr at 3:55 PM on November 2, 2021 [2 favorites]

I just talked to my insurance about this topic today — Aetna, which I just chose over BCBS randomly — and they said it’s definitely an issue of medical insurance rather than your vision plan. I hope you can appeal it. Also, maybe your doctor’s office can try coding it differently?
posted by smorgasbord at 4:52 PM on November 2, 2021 [1 favorite]

Best answer: Ophthalmologist here. I am not your eye doctor, I am not your doctor, I am not a billing expert, this is neither medical, billing, or legal advice, etc.

First off: Health insurance in the US really is ridiculously convoluted. I am sorry you are having to deal with this.

Second: It is generally reasonable for an ophthalmologist to evaluate a patient for ocular migraines.

It sounds like you have a good understanding of the difference between a medical plan and a vision plan. Generally, a medical plan covers medical things, like any kind of eye diagnosis beyond the need for glasses or contacts. Meanwhile, a vision plan will cover basic eye exams, glasses, contact lens evaluations, etc. Vision plans generally do not cover treatment for diagnoses beyond things like nearsightedness, astigmatism, etc.

One place you might consider calling, if you haven't already, is your ophthalmologist's office, and discuss how the visit was billed, whether it was billed to your VSP or your medical plan, etc. Verify that you provided them with your correct insurance information. It's possible that a small adjustment and re-bill could be in order. While on the phone, you might also confirm that the ophthalmologist is in-network with your plan.

If it was indeed billed under your PPO plan, then the EOB from the insurance company might have more information about why the claim was rejected. It gets really confusing to navigate the phone trees, but generally you want to be as accurate as possible, especially when you're selecting the options for vision plans vs medical plans.

Wishing you all the best. This kind of thing is so frustrating and I'm really sorry you're dealing with it.
posted by aquamvidam at 5:09 PM on November 2, 2021 [6 favorites]

That's strange, because BCBS has always paid for my visits to an ophthalmologist who is a retina specialist. As a general rule, the only time my medical insurance has not covered an eye exam has been when the exam produced a prescription for corrective lenses. You should indeed be able to appeal.
posted by metonym at 5:29 PM on November 2, 2021

Best answer: Primary care doctor here: In most cases your medical insurance should eventually pay for this. You will probably have to appeal it. When you appeal it, you should emphasize the "sudden, severe change in vision" which is a totally reasonable reason to urgently see an ophthalmologist to rule out ocular emergencies like acute angle glaucoma, retinal detachment or optic nerve damage. If the issue is that the ophthalmologist is not in network or something, you should add that you were referred there by the ED for, again, an urgent problem, and did not have time to research in-network availability.

My guess is that part of the problem is that the ophthalmologist's office coded the visit as being for "migraine with aura" since there isn't a specific code for "ocular migraine", rather than "acute change in vision," the presenting symptom, and whatever low level bean counter does the first-pass review for these said "aha, migraine is a neurological problem, not an eye problem, we're not covering it" and just rejected the claim instead of, oh, I don't know, just requesting the notes themselves. If you appeal I think you'll have a good chance of getting it covered.
posted by The Elusive Architeuthis at 6:18 PM on November 2, 2021 [5 favorites]

Best answer: What's utterly normal is for someone who works for an American health insurance company to deny coverage for something they know full well that they do in fact cover in the hope of making it enough of a pain in the ass to get them to fulfill their promises that you just sigh and pay it yourself.
posted by GCU Sweet and Full of Grace at 4:20 AM on November 3, 2021 [6 favorites]

Best answer: You may just need to escalate to the next level of customer service rep, not launch a full appeal. I think the reps tend to have a knee-jerk reaction to questions like this where probably 95% of the people who call in about ophthalmology *are* mistaken and think that their regular eye exam should be covered when it's not. Like, I've definitely been treated snippily by a BCBS representative who thought that I didn't understand what my deductible was, probably because she gets a huge number of calls every day from people who don't understand deductibles.

Anyway, first step is to call back and try again, and escalate to the next level of customer support. Lots of other great ideas here including talking to the Dr.'s office. I have *definitely* had ophthalmic care covered by my BCBS PPO, so don't give up hope.
posted by mskyle at 5:51 AM on November 3, 2021

I have BCBS and they do cover eye stuff except for your basics like exams and glasses. I'd call back and escalate.
posted by The_Vegetables at 7:32 AM on November 3, 2021

Best answer: If you do call back or appeal, I would phrase it as "I was evaluated by an opthamologist for a chronic neurological condition that affects my vision and denied coverage". Do not use the word "eyes" to avoid the knee jerk reaction that got you into this hot mess. And absolutely fight it.
posted by Amy93 at 1:53 PM on November 3, 2021

My wife has Type 1 diabetes and her annual diabetic eye exam is always covered by medical insurance, whereas my annual eye exam is not. The medical insurance never covers any resulting glasses or whatever, but the actual eye exam is always covered since it's related to her medical condition. So something related to migraines should be covered too.
posted by COD at 2:34 PM on November 3, 2021 [1 favorite]

I know this is a question about the shitty US insurance system, but in case you're also interested in ocular migraines, I got one a few years ago. I called my doctor, who (IIRC) told me what it probably was, and that it probably wasn't a retinal detachment or anything, so I didn't even go in to get checked out (I stayed at the office and Googled, where I found images that look like what I was seeing.)

I had half a dozen recurrences over a few months, but they've since gone away. I don't know what caused them or why they stopped.

I found the weird visual artifacts quite frustrating -- it was like an out-of-focus blob in my visual field, but there was no optical reason for it. It didn't change with glasses on, glasses off, near, far...nothing. But they'd go away within an hour or two, and they didn't hurt, so ... shrug? I didn't even have to fight with my insurance company about them.

In case you haven't thought to do this, you might start a note file where you list the dates & durations. If they keep happening, you'll be glad you are able to recall them all.

ETA: In my notes file, I have "scintillating scotoma" written down as a good phrase to search for.
posted by spacewrench at 4:27 PM on November 3, 2021 [1 favorite]

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