Insurance Referral Scam?

In My Humble Opinion
1

This is long so bear with me.

Last Monday I went for my first eye exam. The doctor told me I needed reading glasses, not unusual for someone approaching forty. She also told me I had some pressure on my eyes and recommended I get it checked out but the test was covered under medical insurance and not my vision insurance. At this point she did not tell me what the test was or the name of condition she thought I may have or be getting.

I picked out what frames I wanted and was told they would be ready in a week and that I would also get a call to set up an appointment for the other test and they are done on Saturdays. I was sort of surprised as most doctors do not work on Saturdays but cool that means no time off work.

I never got a call other than on Friday to tell me my glasses were ready. I went in and got my glasses and she mentioned that I would be back tomorrow for the test.

I told her no as I never got a call and was not sure if it was covered under my medical. She was surprised I never got a call and asked her secretary to call whoever the person was that was supposed to call me but she got no answer. They took a copy of my medical card and told me to come back at noon on Saturday. I agreed and she said “We will see you then”.

I googled yesterday morning and realized the test was most likely for glaucoma. I read the sort of tests they do and what not. I don’t know why she just did not say it was a glaucoma test. I mean it seems to be a pretty common test.

So come noon I show up. There is different doctor in an adjoining office, my vision doctor was not there but my vision doctors secretary is there. Now this is when I was sort of surprised as they made it sound like a different person was the one that failed to call me. If this lady was the secretary for both doctors is she not the one that should have called? Weird I thought but hey maybe there is a third person. I am also surprised that there is a different doctor. She never said that a different doctor was doing the tests. She made it appear as though she was the doctor but the test was just covered under medical rather than vision.

So the secretary gives me the forms for the new doctor. Not a real issue but I am sort of miffed that this whole procedure was not explained to me. I am miffed at myself for not asking more questions. So I fill them all out and wait again. They call me in and as I am walking up the doctor comments that they will need $200 copay as they do not know if he is an in-network provider and $200 is the out of network copay. I mean is that not the purpose of taking the copy of my card? To check for coverage and get copay amounts. Since I thought the vision doctor was doing it I assumed she new if she was an in-network doctor.

I explained then that I was not going to pay that amount. I did not even know his name or the name of the test so I could confirm the insurance coverage. I had assumed the vision doctor was doing the test and was covered as they are the ones that took a copy of my medical card. I did not know they were doing it for another doctor.

So I left pissed off for wasting my time.

The more I thought about it I wondered if it was some type of insurance scam. Did I really have this pressure on my eyes or did the vision doctor just say that so she could drum up business for the other doctor? Maybe they are related? Is this father in law or father for that matter?

The lack of information on what the pressure was and what it was actually called or what the test entails, the lack of information that it was a separate doctor and the lack of the phone call to inform me of all these things makes me feel like they are pulling a fast one on patients. If the copay had been only $35 for an in network provider then I would have gotten the test.

I wonder how many people with medical coverage have had this happen to them. There were three other people in the waiting room all filling out new forms and shelling out copays. Did they get more information than me or did they as well just get a “you have pressure on your eyes and I suggest you get tested” with no other information.

Do you think that this might be some type of referral scam?

I know doctors recommend other doctors and I think that is fine but this whole thing makes me feel that because of the lack of information they give that this is some sort of a set up and that once you are there and your insurance covers it that most people are going to just go through with it.

They did give me two copies of his card. One shows the address I was at and the other shows an address over 91 miles away. Both cards also show he is an Assistant Clinical Professor at a Major University but he has a hotmail email address. Would he not have a University address?

Maybe I am being paranoid but the whole thing sort of made me feel like it was a scam of some sort.

2

Just a couple things since I know jack about insurance but do know something about ophthalmology:

I know a few ophthalmologists who are university professors and attending physicians at hospitals but use non-“official” addresses. I think they figure that even if they move on to another location, they plan on always having that address as a main contact, so that colleagues, pharmaceutical companies, etc., will know how to reach them. I suspect the two addresses were the practices he covers on different days - the doctors I work for have a network of “satellite” clinics they travel to, to care for patients around this area, and are based at a university-associated medical center.

The doctor probably didn’t call it a test for glaucoma since hearing that tends to freak people out. Also, it’s not common at all but they might find low pressure in the eye which is caused by other conditions. The doctors also have no idea if you have elevated eye pressure without that test - or if they do have an idea, it means you’re showing a lot of other symptoms of elevated eye pressure which is a bad thing (see my post in your other thread). It’s a good idea to get the test when you get older as high eye pressure is the earliest warning sign of glaucoma, and really the only one until you start showing significant loss of vision. The test is also pretty common; where I work we typically check the eye pressure of most every patient.

What degree does your first eye doctor have behind her name? An OD is a doctor of optometry, aka optometrist. (The people who fit you for glasses are opticians, they can’t even write glasses prescriptions.) ODs can do examinations, give prescriptions for lenses, and do some testing. They cannot prescribe medications, and typically refer to an ophthalmologist, who is a MD, for more complicated eye disorders/diagnoses. An OD would probably do a pressure test, though. I can’t recall from my optometrist visits if pressure checks are covered under vision insurance, but then again my impression is that typically little is covered, at least with the plans I had. :stuck_out_tongue:

If you’re concerned, I might suggest you talk to your insurance company or your regular physician. See if a referral to a general ophthalmologist would be possible and covered under your medical insurance.

3

I’ve never gone to an optometrist who didn’t do a pressure test as part of the regular exam, for everybody from all appearances, though I do have a bit of family history of glaucoma so they would test me even if they didn’t test everybody. I’ve also never had vision insurance, so I have no idea whether it’s normally covered or not, but I’d be surprised if it wasn’t.

This whole situation sounds really strange.

4

I work for an optometrist and all her patients are pretested with a pressure check (it’s the little puff in your eye test…how’s that for the technical name? :)). It’s included in her exam fee. I agree with whiterabbit. It does sound really strange.

5

They did the puff in the eye test. She asked if I had high blood pressure which according to my last check up I do not have.

That is when she suggested I have another test. She never said the name of the test, maybe not to freak me out, or that a different doctor would be doing it. That is what sort of made me angry. She did not give me much information. If I had known I would have made sure the procedure and the doctor were covered under my medical insurance.

She is listed as an O.D. She gave me three tests on three different machines, one being the puff test. After she explained about the reading glasses and the other test to check for pressure in my eyes. She had me pick out frames from a different small room adjoined to the main waiting area and I picked up my glasses a week later.

It sounds from what I read in my other thread that a pair of drug store $9.99 glasses would do but the doctor had me pick frames from her selection. $110 frames completely covered by my insurance other than a $10 copay. Lenses are completely covered as well with another $10 copay. I can get new lenses every year and new frames every two years.

The other doctor is listed as a M.D, Assistant Clinical Professor of Ophthalmology.

From what I read about Glaucoma tests they most likely would have dilated my eyes, also not mentioned, which means I would not have been able to drive home as I went alone.

6

Dilation would have happened if they wanted to look into your eye at your optic nerve.* That’s to see if there are any visible signs of pressure damage to the nerve. This method of looking inside the eye typically involves a headlamp on the doctor and him or her peering through a hand-held lens into your eye, not the “put your chin in the chinrest” type of looking into your eyes. (The latter examines the outside part of the eye, including the lens and the chamber surrounding it.) You don’t need dilation for standard pressure checks.

As for the other test, I’m not sure what they might have been doing. Could be a Humphrey visual field test which would pick up glaucoma-related changes in your vision. Could be another pressure-type test. I’ve seen a couple patients have the thickness of their cornea tested - if you have naturally thick corneas, your pressures can wrongly register as high.

If you’re worried, request a copy of your records, then check through your insurance and/or your primary care physician to see if you need an ophthalmology referral and can get one inside your network. The main reason for referral would be a high pressure, typically listed on the sheet as “IOP” and with two numbers, right eye and left eye in that order.

I do have to say that the optometrist sucks for not explaining the situation better, especially since vision insurance and medical insurance are typically separate and you weren’t prepared for the possibility that your insurance wouldn’t cover it.

  • There are other reasons to look deep into the eye and thus require dilation, not just glaucoma evaluations.
7

That is why I wondered if it was some type of referral scam for people with medical coverage.

If she had said "You appear to have pressure on your eye(s) that has been determined by the “puff test”. I recommend you get tested for Glaucoma. This is a medical procedure that is normally covered by medical insurance and is performed by an ophthalmologist. Dr. Eyedoc comes into this office on Saturday to perform these tests so you can make an appointment with him. Here is his number.

But she did not explain any of it. I suppose the person that was suppose to call me was going to do that but I never got a call. It felt like I was railroaded into it at the last minute when I picked up my glasses and then wasted on hour of my time on Saturday only to find out Dr. Eyedoc was not even covered by my insurance.

I will look into a doctor that is covered and get the test. I assume I will need a copy of my medical records anyway to give to the doctor so I can see what it says.

8

I agree. At the very least they were not professional in how they handled the situation. I find even in our offices sometimes people don’t explain things because they’re so used to doing something habitually that for them it’s second nature, but the patient might not be so accustomed to it, whether it’s an eyedrop that stings or a test that flashes lights at you, or whatever. I don’t know if the office you went to are scamming - it’s not unusual for optometry practices to have associated ophthalmologists - but regardless they could have cost you a lot of money that you might not have wanted to pay and your insurance might have refused.

9

I made a point to tell the doctor that this was my very first eye exam so I would have thought that she would have explained things more.

She did not tell me what each test was suppose to be looking for nor did she warn me about the puff test. I was looking in the view thing and then boom a blast of air.

I went to her not only because she is two minutes from my house but that I knew other people that went to her and liked her. They are people that wore glasses their entire lives or most of it so they are more familiar with getting eye exams and having tests done than I am.

10

I am not on board with a referral “scam”. From your story, I think what happened it your test was a bit off and the doc wanted you to see a specialist. Just because they work in the same office, doesn’t mean they share the same business name or receipts…probably just share overhead.

I vote for total inefficiency by the part of the office. You should have been given the name of the test and the doctor so you could call to check your coverage. Obviously, they didn’t know and were covering their butts so they get paid by someone and that someone was you.

I certainly would see about getting the recommended test or a second opinion. You obviously (and rightfully) have no confidence in this office so get your records and see another specialist. One that is par with your plan preferably. Good luck.

11

I’ve never had my eyes dilated for a glaucoma test. The other test I’ve had besides the puff test (which I hate) involves them using numbing eyedrops and then touching my eye with a wand thing. It sounds weirder than it is.

I certainly hope this is an incredibly disorganized office. I’d still go elsewhere, though, after going through all that. There’s no reason for you to stay with them unless you wanted to.