Blurry Line Between Medical and Vision Insurance Leaves Patient With Unexpected Bill

Barbara Tuszynski was concerned about her vision but confident in her insurance coverage when she visited an eye clinic last May.

The retiree, 70, was diagnosed with glaucoma in her right eye in 2019. She had a laser procedure to treat it in 2022 and she uses medicated drops in both eyes to prevent further damage. She is supposed to be checked regularly, she said.

At the May appointment, Tuszynski’s optometrist examined her eyes and reassured her that the glaucoma had not worsened.

Tuszynski, who lives in central Wisconsin, had checked beforehand to see if the nearby Madison clinic participated in his insurance plan. The insurer’s website listed the optometrist’s name with a green check mark and the words “in network.” She assumed that meant her policy would cover the appointment.

Then the bill arrived.

The medical procedure

An optometrist tested Tuszynski’s vision and took photos of his optic nerves.

The final bill

$340, including $120 for vision tests and $100 for optic nerve imaging.

The billing problem: visual coverage and medical coverage

Tuszynski’s UnitedHealthcare Medicare Advantage plan refused to pay for her eye appointment. “Member does not receive any out-of-network benefits,” the company’s denial letter states.

Tuszynski felt like he was seeing double. How can an ophthalmologist be both in-network and out-of-network? She said she sent the insurer a screenshot of her own web page showing the clinic listed as in-network.

She said that after her complaint, UnitedHealthcare representatives explained that the eye clinic was in-network as part of its vision plan, so its policy would cover the clinic’s services related to glasses or contact lenses. But they said the clinic was not in-network for its medical insurance plan and that treating glaucoma was considered a medical condition.

Tuszynski was baffled that a patient’s eye care wouldn’t be covered by vision insurance. She said she didn’t realize insurers might have contracts with eye clinics to provide some services but not others.

UnitedHealthcare spokeswoman Meg Sergel said such arrangements are common, including with non-Medicare insurance provided by employers or purchased by individuals. “I went to my eye doctor and it’s the same thing,” she said in an interview with KFF Health News.

Sergel said she understands how a customer might mistakenly think that vision insurance would cover all eye care. She said UnitedHealthcare recommends that before undergoing treatment, patients ask health care providers if they are in-network for specific services.

Otherwise, she says, to know if a test or treatment is covered by vision insurance, “you would have to read the details” of an insurance policy.

Executives at the Steinhauer Family Eye Clinic, where Tuszynski saw the optometrist, declined to comment.

Casey Schwarz, senior adviser for education and federal policy at the nonprofit Medicare Rights Center, said such complications frequently arise when Medicare Advantage members try to use their insurance at eye clinics or dental offices.

The federal government pays insurers to manage Medicare Advantage plans for people who choose them instead of traditional Medicare. More than half of Medicare beneficiaries are enrolled in private plans. Many offer routine vision and dental coverage that is not included in traditional health insurance.

“We hear from people who choose these plans because of these added benefits, but there’s not a lot of transparency about them,” Schwarz said.

The resolution

After receiving the rejection letter, Tuszynski repeatedly contacted UnitedHealthcare to question the decision and filed an appeal with the company. Then, she said, she called a Medicare hotline to complain to federal officials. She also wrote to KFF Health News, which asked the insurer about the matter.

UnitedHealthcare ultimately agreed to cover the bill as if the service had been in-network. “In good faith, we made an exception,” Sergel said. However, Tuszynski was warned that if she received medical care from the clinic again, it would not be covered because the clinic remains out of network for such services, Sergel said. “It doesn’t seem like he likes it.”

Tuszynski confirmed she was not happy.

She said she lost sleep over the dispute and felt it shouldn’t have taken so much effort to get a fair outcome. “It’s been a horrible, difficult whirlwind,” she said.

Takeaways

Schwarz said regulators should require insurance companies to clearly explain to customers and health care providers how different procedures and services will be covered under vision, dental and health plans. “They’re delicate,” she said.

In an ideal world, Schwarz said, Medicare would consider things like dental cleanings, eye exams and hearing aids as basic health care that would be covered the same as other medical care. But in the meantime, she said, patients who have doubts should call their insurer beforehand to check whether services will be covered.

Tricia Neuman, senior vice president of KFF, a nonprofit health news organization that includes KFF Health News, noted that the Medicare website now includes a tool that can help people determine whether their doctors participate in a Medicare Advantage plan.

“It’s helpful and a step forward, but the information about provider networks is not always correct,” Neuman said. “Errors can come at a cost to enrollees unless they are willing and able to take it to their insurer.”

Tuszynski worked for 30 years as a secretary in hospitals and doctors’ offices, so she is familiar with billing issues, she said. “If I can’t fix this, how can anyone else? »

She knows her $340 bill was far less than the medical debt many other people face. But she said it was a significant amount of money for her, and she was glad she objected to the insurer’s contention that the bill shouldn’t be covered.

“I have a strong sense of right and wrong – and it’s just wrong,” she said.

For 2026, she decided to drop her Medicare Advantage plan. She is now enrolled in traditional Medicare, as well as a supplemental plan to help cover co-pays and other costs. She pays $184 per month for this plan, whereas she paid no separate premium for her old Medicare Advantage plan.

Now she won’t have to worry about private insurers’ limited networks of contracted care providers, she said. Her glaucoma treatment will be covered at the Madison Eye Clinic.

However, she no longer has insurance coverage for glasses, only a discount plan if she buys glasses in certain stores. She used her Medicare Advantage insurance to buy new glasses shortly before making the switch. “I hope it lasts me a while,” she said.

Bill of the Month is a participatory survey conducted by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers reduce their medical bills, and it has been cited in states, at the U.S. Capitol, and at the White House. Do you have a confusing or scandalous medical bill you want to share? Tell us about it!