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Highmark change in Medicare eye exam coverage irks some

Ruediger | Leader Times
Dr. Paul Lobby of Kittanning is pictured with a Phoropter that is used to give refraction examinations to his patients. Thursday November 15, 2012 Louis B.

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Visits to eye doctors gave some seniors a surprise this year: They paid out of pocket for a refraction eye exam.

Refraction testing — a term familiar to people who wear glasses — involves viewing an eye chart while looking through various lenses to determine the strength of glasses needed.

Highmark Inc., the predominant health care insurer in Western Pennsylvania, stopped reimbursing for the test as a medical expense under its two Medicare Advantage plans with nearly 195,000 members in the region.

The test typically costs $43, Highmark says.

Until Jan. 1, Highmark allowed eye doctors treating Medicare Advantage members to bill for a medical eye exam, such as checking a diabetic patient's eyes for problems, and for the refraction test.

Highmark said it stopped the double-dipping practice because its members with either FreedomBlue PPO or Security Blue HMO also have Davis Vision insurance, which covers refraction exams and eyeglasses.

“We review medical policy on an ongoing basis, and this duplicate benefit was identified and implemented for a benefit change,” Highmark spokeswoman Kristin Ash said.

Medicare Advantage plans are a type of Medicare health plan for retirees. Private insurers contract with the government to provide doctor and hospital benefits. The nation's Medicare program never covered refraction.

Ash could not say when Highmark began covering refraction as a medical benefit in its two Medicare Advantage plans.

UPMC Health Plan, the second-largest insurer in the region, does not cover refraction as a medical benefit under the Medicare Advantage plans it markets as UPMC for Life, spokeswoman Gina Pferdehirt said. All UPMC for Life plans come with vision insurance that cover refraction, she said.

Dr. Alexander Chang, a Green Tree ophthalmologist, said the change creates problems for his patients, because Highmark doesn't allow eye doctors to charge Security Blue or FreedomBlue for a medical eye exam and Davis Vision for a refraction on the same day, he said.

“You cannot bill the two insurances on the same day or for the same visit,” he said. “That's against their policies.”

Chang said he and other eye doctors around Pittsburgh are telling patients with Highmark Medicare Advantage plans that if they want the refraction test when they get a medical eye exam they'll have to pay $30, or come back another day.

Dr. Paul Lobby, a Kittanning optometrist, said the change isn't a problem for his practice. Though he suspects not many colleagues agree, Lobby said Highmark told him the reimbursement for a medical eye exam includes refraction testing.

“The medical exam includes evaluating the refraction status of the eye,” he said. “It's really a matter of interpretation.”

Lobby sits on a committee for the Pennsylvania Optometric Association that works with insurers on policy issues. The Harrisburg-based trade group discussed Highmark's change and didn't oppose it, Lobby said.

“I think they know we were a little disappointed with the decision,” he said of Highmark executives. “I don't think we thought it was a battle worth fighting.”

Alex Nixon is a staff writer for Trib Total Media. He can be reached at 412-320-7928 or anixon@tribweb.com.

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