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Medical Forum / General / Vision / November 2006

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Vision insurance claim question

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tapsen7@gmail.com - 22 Nov 2006 23:30 GMT
I had a question about a vision insurance claim problem.  Here's the
story -

I found this doctor (Doctor A) listed under my in-netowrk provider,
under my vision insurance plan.  Made an appointment for an eye
examination.  The exam is covered-in-full for the in-network provider
(per the benefits documentation).  Went there. Unfortunately, did not
have my id card.  But my provider (OptiChoice) had told me the new name
- DavisVision (they will be merging into this new company) as the
company name.  So I told the front-desk receptionist this name.  She
did a search using my SSN, but did not find me under this company.

I decided to pay for the exam beforehand, knowing that I can get a
claim afterwards.  I was seen by a Doctor B, in that office.  Paid
$100.

Called my insurance company to get the details on getting my claim.
They called the doctor's office for more details.  There the
receptionist told the company that Doctor B was not in the network,
hence I'd just be re-imbursed $32 (out-of-network).

So my question - is this ethical.  My eye prescription had Doctor A &
Doctor B's name on it.  I went there knowing that this office is in the
network.  But then I got this surprise that this Doctor B is not.  What
are my options to get this rectified.  Welcome any suggestions.

Thanks.
Mike Tyner - 23 Nov 2006 00:21 GMT
> Called my insurance company to get the details on getting my claim.
> They called the doctor's office for more details.  There the
> receptionist told the company that Doctor B was not in the network,
> hence I'd just be re-imbursed $32 (out-of-network).

Some plans don't reimburse the doctor much more than that. In this case, if
you discussed Optichoice *before* the exam, it was up to that person on the
phone to let you know that Dr. A was in the network and Dr. B wasn't.

If that's true, you could make a case asking the doctor B for a refund.

In my office, if we didn't explain that Dr. B wasn't on your plan, I would
think we screwed up.

> So my question - is this ethical.

It might not have been intentional, but it was unfair. Intentional or
repeated bait-and-switch can be called fraud.

> My eye prescription had Doctor A &
> Doctor B's name on it.  I went there knowing that this office is in the
> network.  But then I got this surprise that this Doctor B is not.  What
> are my options to get this rectified.  Welcome any suggestions.

It's time to put it in a letter to both of them. Don't rant or threaten, but
present your case and tell them you think a refund would be fair.

If they balk, you might settle for a refund of the difference between your
$100 and what Optichoice would have paid them. But I'd be surprised if they
collect more than $60 routinely.

If your brother-in-law is a lawyer, you might take it further. But it's just
a hundred bucks. You could do more damage with a letter to the Better
Business Bureau, or the state insurance commission.

-MT
Glenn - USAEyes.org - 23 Nov 2006 01:02 GMT
A written notification to the insurance company would be appropriate
as well. If this was merely an accident, then it probably rarely
happens. If this is an intentional method to upcharge people with
insurance plans that pay poorly, then your insurance company would
want to know that their beneficiaries are being poorly treated.

It sounds to me like an honest mistake due, in part, to you not having
your insurance card with you. Give your doctors the benefit of the
doubt, and notify them of the problem. Give them the opportunity to be
heroes.

Consider some alternative methods of reimbursement too. Perhaps a
certificate for next year's exam or money off contacts, sunglasses,
etc. I'm sure they want to keep your business, and this may be a good
way for both of you to come out ahead.

Glenn Hagele
Executive Director
USAEyes.org
Patient Advocacy Surgeon Certification

"Consider and Choose With Confidence"

Email to glenn dot hagele at usaeyes dot org

http://www.USAEyes.org
http://www.ComplicatedEyes.org

I am not a doctor.

Copyright 2006
All Rights Reserved

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