I feel like a broken record...

I have a lot of patients who think that their "well vision"/vision
discount plan (e.g., VSP Standard Plan, Medical Eye Services, Davis
Vision, EyeMed, Spectera, etc.) covers everything eye related.

They will come in with complaints such as eye pain, red eyes, dry
eyes, flashes/floaters, epiphora, foreign body sensations, sudden
vision loss, transient loss of vision, itchy eyes -- in other words,
non-refractive complaints/complaints not amenable to standard optical
correction (i.e., glasses).

I get put in the unfortunate (and complete waste of time) position of
having to explaint to patients how THEIR *routine* vision insurance
works.  How their VSP, *MEDICAL* eye services, Eye*MED* (aside:  How
stupid to call yourself "MEDICAL eye services" or "EyeMED" and not
cover MEDICAL eye problems.) does not cover anything beyond a glasses
examination and screening for eye disease.

In other words, if someone comes in with complaints that suggest dry
eye, it does not cover the Schirmer's test necessary for the diagnosis
and it does not cover the follow-ups necessary for me to judge
response to therapy (Some people need merely enviornmental changes,
others need artifical tears, others need nutritional supplementation/
omega-3 oils, others need corticosteroids, others need eyelid hygiene,
others oral tetracyclines, others RESTASIS, etc.) and monitor for side
effects.  If someone comes in with complaints of transient vision loss
or loss of side vision, it does not cover the perimetry I feel is
needed for the workup.  If someone comes in with an acute floater, it
does not cover the extended ophthalmoscopy that is all likelihood
needed.  And if someone comes in with what I suspect to be bacterial
keratitis, it does not cover the culturing of the ulcer (if needed)
and it does not cover the follow-ups needed to judge (and possible
modify) the response to therapy.  Etc -- I think you get the idea.

And some complaints (e.g., headache, decreased vision) have refractive
and/or medical causes.  And a refractive cause cannot be ruled out
prior to performing a routine eye examination.

The unfortunate fact of life where I practice (Southern California) is
that approximately 75% of the people I deal with are touched in one
way or another via managed care/HMOs.  So it is NOT, in the majority
of situations, a case where I can simply bill their major medical
insurance and it will reimburse me.

And the vast majority of these managed care patients want to be seen
only if their insurance will cover their visit, so explaining the
rationale for treatment, epidemiology, natural history/course, various
risks/benefits of treatment, treatment/management options is a
complete waste of time.  Some even have the gall to ask me what they
can do themselves to treat their complaints without having to go to
their HMO since I just "examined their eyes."  One particular dry-eyed
patient wanted me to tell her what she should try first before going
to her HMO, because if she went to her HMO she'd have to take time off
work, see her primary care doctor, who then may or may not refer her
to an eye specialist for which she'd have to take more time off work
and all this "would take probably weeks because that's how long
referrals to specialists take".  But she also did not want to have to
pay out of pocket for the workup and follow-up visit if I were to
start empirical dry-eye treatment.  She felt I should just tell her
since I just "examined her eyes" using her vision disount plan's
benefit.

I don't want to offend patients, but I also want to make it crystal
clear that our office does not provide free services for those who can
afford to pay for them or those who have medical insurance that would
cover them to go elsewhere.  Their choices are to either pay us or go
through their HMO for non-covered services -- it should be cut and
dry.  Also, vision insurance pays pennies on the dollars of what a
cash patient does and as such there is even less incentive on vision
insurance patients to provide anything in the form of free service.
Lastly, if I would provide these "free services", there would be
reduced incentive for medical insurances to put me on their panel or
for patients to choose PPO over HMO.  Patients need to realize that
they don't get PPO service (go where they want, when they want) at HMO
prices.  That's why people get HMOs because they value the less out of
pocket expense over the more flexibility they get with a PPO.

I have gone to various vision discount plan webpages and manuals and
see nothing that clearly states to the patient that non-refractive
(i.e., medical) eye problems are not a covered benefit.  I suspect
they make it intentionally vague along with the human resource
departments at the various companies that contract out with such
vision discount plans.  I get a bunch of patients who call their jobs'
HR departments and tell them "I got pink eye" to which the HR
department tells them they have VSP standard plan and go see on  of
the doctors on the list rather than directing them thru their medical
insurance.  I mean -- WTF -- the HR/employee benefits department
doesn't even know what the VSP does and does not cover?  Same with
EyeMed, MES, etc.  I would like to have something in writing that I
could show to a patient to demonstrate this fact.  In other words to
say, "Look.  Sorry.  See right here.  Your VSP standard plan doesn't
cover the evaluation, workup, management and treatment of your
complaint."

It is not an exaggeration that having to explain this to patients is a
valuable waste of our time.  Waste as in, it is clearly not our
responsibility to explain to patients their insurance benefits.  There
are certainly cases where it is unclear ("My eyes are bothering me")
if the problem is refractive or medical, but the majority of the cases
are clear if patients would merely know what their insurance covers.
Vision/medical insurance is not a contract between the doctor and the
patient, but between the patient and the insurance company and the
doctor and the insurance company.

Does anyone have anything in writing from one of these vision discount
plans manual or website that clearly states what is and is not
covered?  And how do other eye doctors deal with patients who present
with such problems?