Medicare has already become a system to be gamed. A Medicare patient went to an optometrist for new glasses, knowing that glasses are not covered under Medicare. When asked for an insurance card, she said she did not have insurance for glasses, but they wanted the Medicare card anyway.She had a rather comprehensive examination, was given a new prescription for lenses and proceeded to choose her frames and pay for her new glasses.
Several months later, she received a “Medicare Summary Notice for Part B.” Medicare was billed $817.09, approved $552.07, and paid out $432.82. The patient was told that the maximum she may be billed would be $110.41, or 20 percent of the approved amount. She never received a bill.
Rather shocked at those numbers, she looked more closely at the charges that were approved:
Eye and medical exam for diagnosis and treatment, new patient: $147.01
Photography of content of eyes: $20.41
Examination of right eye by ophthalmoscope with retinal drawing: $26.01
Examination of left eye by ophthalmoscope with retinal drawing: $26.01
Photography of the retina: $58.17
Microscopic evaluation of deep cells of the eye: $40.24
Ultrasound of eye disease, growth, or structure (right): $79.79
Ultrasound of eye disease, growth, or structure (left): $79.79
Measurement of field of vision during daylight conditions: $74.64
TOTAL for CLAIM APPROVED: $552.07
TOTAL PAID by Medicare: $432.82
All this for a healthy, asymptomatic patient who just needs new glasses! It is clear that Medicare has become a cash cow for enterprising “providers.” This does not appear to be fraud, just creative billing for services that were not asked for and probably not needed. Medicare was willing to pay, but the self-paying patient might have been content with item No. 1 only, unless it revealed a cause for concern. And what is No. 6? An ophthalmoscope is a microscope for examining the deeper structures (see Nos. 3 and 4), and a slit lamp is a microscope for looking at the structures in front. All eye examinations by an eye doctor would routinely include these for both eyes every time.