| Answers to your insurance questions Insurance and health care has become extremely complex over the past decade. We at Ridgewood Ophthalmology are on your side, and we will do everything we can to help you! Here are the most frequently asked questions to orient you to this strange new world. Will my insurance pay for the entire visit? Why wouldn't my insurance company pay if I have a valid referral? What is an "invalid" referral? Why do I have to get a referral? Why don't you get it for me? Do I have to get a referral every time I visit? But this is a follow-up at the doctor's request; why do I need a referral? Why don't you "participate" in Medicare? What does this mean? Do you file my Medicare insurance? Are contact lenses covered by insurance? Is LASIK covered by insurance? Will my insurance pay for the entire visit? Probably not. Your insurance will likely pay part of your visit, but not the entire cost. You may still have to pay a co-pay, your insurance may or may not cover eye exams, you may not have met your deductible, and you may have uncovered services, like contact lenses, LASIK, or refraction. Your insurance plan may require you to pay a "co-pay," that is, a sum of money out of your own pocket, every time you visit. This is determined by the kind of plan you are in. Co-pays can range from $5 to $45. The insurance company requires us to collect it at the time of your visit. You may not be billed for the co-pay. A deductible is the amount of money you must spend before your health insurance covers anything. It can range from the first $500 to the first $4,000 you spend a year on health care. A refraction is when your eye M.D. tests your vision for distance and reading with the best possible lenses, to determine your correction for distance and near, and to determine what is your best corrected vision. This is obviously an integral part of every eye exam. Our fee is $45 for refraction. Some insurance companies cover it; some cover it in part; other insurance companies do not cover it at all. Insurance companies set our rates, and determine how we "code" for your visit, and they have designated it as a separate part of the visit.
A referral is a very specific term in health insurance; it does not mean that your doctor suggested you get an eye exam. It means a slip of paper or an electronic code number indicating that your doctor (who is designated your Primary Care Doctor for that health plan) has authorized your visit with us, and that the insurance company will pay for it, provided all of the insurance company's requirements have been met. A referral does not guarantee that your visit is covered. We cannot tell you what your specific plan requires. You need to read your insurance card, call your Primary Care Doctor, or check with your Human Resources Department at work. Why wouldn't my insurance company pay if I have a valid referral? Patients with valid referrals have had to pay in the past for the visit because their condition (nearsightedness, needing reading glasses) wasn't covered by their health insurance. What is an "invalid" referral? An invalid referral is an out-of-date referral, or a referral from a doctor who is not your designated Primary Care Doctor. Specialists (like us) cannot give referrals.
Why do I have to get a referral? Why don't you get it for me? The patient has to get the referral. This is because the insurance companies want to lower health care costs by sending you first to your Primary Care Doctor, who may be able to treat you at less cost than sending you to a specialist. Do I have to get a referral every time I visit? In general, yes. You must check with your health care plan. Sometimes your referral doesn't cover every test you will need, and you may have to go back to your Primary Care Doctor to get another referral for additional testing, such as a visual field test. We cannot tell you what your specific plan requires. But this is a follow-up at the doctor's request; why do I need a referral? Specialists like our Eye M.D.'s are not allowed to give any referrals of any kind; if you need a follow-up, you almost always need another referral, every time. Why don't you "participate" in Medicare? What does this mean? "Participating" and "nonparticipating" is a specific but odd use of the word by insurance companies, and now what you think. It is a confusing term! We don't "participate" in Medicare; we are listed as "non-participating" doctors. We do see Medicare patients, and Medicare sets all of our fees, and Medicare does cover some or part of the visit, but usually not all. "Participating" is a special designation meaning the doctor bills Medicare, and Medicare then pays the doctor directly. "Non-participating" means you see the doctor, you pay the doctor, the doctor bills Medicare, and you receive a check in the mail in 30 to 40 days from Medicare.
Do you file my Medicare insurance? Yes, we file your Medicare insurance claim. Are contact lenses covered by insurance? Is LASIK covered by insurance? Usually not. Special: Read about what cataract surgery is like, from the patient's perspective! One of Dr. Sumers' cataract surgery patients published this article in the Bergen Record. |
Home | News | Our Doctors | Eyewear | LASIK | Insurance Questions | Comments | Directions
Ridgewood Ophthalmology • 1200 East Ridgewood Ave., Ridgewood, NJ 07450 • (201) 612-0044 • Fax: (201) 612-9466