WHY DOES MEDICARE STILL PAY FOR POST-SURGERY CATARACT GLASSES?

**Bob Rihl** · 08-16-2000, 01:18 AM

Where Medicare first came in, Opticians and Dentists were relieved because it specifically excluded eyeglasses and dental care.
Then, a year or so late, some jerk figured out that since the crystaline lens of the eye was removed during cataract surgery, that the thick aphakic eyeglasses and contact lenses were a prosthesis, or bodilly organ replacement, so people who were without a lens in their eye, being totally dependent on the thick glasses or contact lenses, were entitled to reimbursement on that basis. Of course, it was no problem for us, because back then, you just wrote out a rceipt that said "cataract glasses", gave it to the customer, and THEY went to te post office, stapled the receipt to a form, filled in the stats themselves, and mailed it in.
But now, the IMPLANT is the prosthesis, or bodilly organ replacement. So why does Medicare still pay for even the first lens after surgery? Those old folks would need a lens like that ANYHOW. And in most cases, the lens they get is a heck of a lot weaker than their old one was. It's usually plano, with a little cylinder, and an add, which they would have needed if no surgery had been done.
Medicare could save millions, maybe billions, if they would wise up and cut out this freebe. And now, Opticians are required to fillin the form FOR the customer, and code everything. I hate Medicare. It has ruined our healthcare system, and led to the creation of all these HMOs and PPOs and so forth. People expect the government to provide for all their needs. I've looked over the constitution, and can't find ANYTHING that says that the government "shall provide health care for the elderly." Much less a pair of glasses, which EVERYBODY over about forty needs. I'm almost ready for Medicare myself, but would gladly give it up if it would just go away.
But why glasses, when the IMPLANT is now the replacement lens, not theglasses, like it used to be?
Cranky Bob

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"Come see me now, heah?"

**Tammy** · 08-16-2000, 10:56 AM

Hello Cranky BOB,

I sure hope that if I have the need one day to replace my cataract lens that Medicare will cover my glasses post operative, and If I ever was aphakic that Medicare would pay for a lifetime of Contacts and Glasses so that I would be able to see. A lens is a body part and without it I can't imagine what life would be like.

When I was a Technician and worked for a Corneal Transplant Group, we would see patients 1 day post op and tears would be coming from their eyes due to the fact that they could see for the first time in years and they would immediately talk about the changes they were going to experience due to the fact that they could visualize everything around them. They had regained their Life as they once knew it.

So if Medicare is going to pay for a body part that has been taken away from them, then I'm all for it, I just hope that by the time I become of age for Medicare and have suffered the loss of a lens, That the benefit will still be available for me. Life at the age of 70 is hard enough, and lets not mention money, I'm in this business because I care, and if I need to be a patient advocate for insurance purposes (which I am) then I will do whatever the government tells me to do to be compliant, the fact is its the LAW to bill for these patients and I'm not going to break it.

Your friend in the billing department,

Tammy

**Pete Hanlin** · 08-16-2000, 11:02 AM

I've looked over the constitution, and can't find ANYTHING that says that the government "shall provide health care for the elderly."

Bob,
Actually, I've often wondered why Medicare continues to pay for post-cataract lenses myself- especially considering we tell them the patient has an IOL every time we enter the V43 code (pseudophakia) on the claim...

On a human note, however, I have to ask you "Where's the compassion?" Of course it's our responsibility as hard working Americans to provide for those who can't work, don't want to work, or didn't plan for a future after work. I, for one, am happy to make my contribution to our Great Society every two weeks on payday.

Pete "but that's better said on another forum, I suppose" Hanlin

PS- I don't think Bob was suggesting that Medicare no longer pay for an IOL- just the bifocals that are needed afterwards.

[This message has been edited by Pete Hanlin (edited 08-16-2000).]

**Bev Heishman** · 08-16-2000, 11:35 AM

Gees Bob, I can understand your frustration but I agree with Tammy and Pete.

Aphakes and Psuedophakes have different reimbursement types.

The psuedophake usually only recieves one pair of spectacles per eye done per lifetime because the bulk of expenditure occurs in the replacement of the crystalline lens with an IOL. This is ok to me because the eye has been returned for the most part to that of a presbyope with out the aging natural lens.

The aphake and there are still some around that are not implantable are having their vision replaced with a spectacle lens outside their bodies with all the inherent problems that go along with this type of correction. Some wear contact lenses that are also reimburseable (at specified frequencies).

The aphakes that I have worked with and use glasses as a modality generally do not replace them on yearly visits. I find many who wait as long as they can because of frame size limitations and appearance.

Have a great day!

**Texas Ranger** · 08-16-2000, 12:33 PM

Bob, Medicare used to pay for pseudophakic lens yearly, until dispensing surgeons abused the system to the point of them limiting to one lifetime lens, which is absurd. Medicare pays because people still can't see very well after the IOL, without spectacles. it's our guvment tryin to do the best we can. i think they should pay for new lens every three years though. the paperwork deal is somebody's nightmare though!

**Tammy** · 08-16-2000, 12:45 PM

Al,

I can honestly say that the paperwork is not a nightmare. I bill everyday for DME and as long as you follow the rules its a breeze. I have been doing this for 17 years and have seen all the changes, key word changes....you must always keep up and follow up....not to blow my own horn but follow-up is not that difficult when you have a competent MEDICAL biller.

Your friend in the billing department,

Tammy

p.s. hey bob I know a great biller if you need one.

**Chad Huber** · 08-16-2000, 12:57 PM

First of all let me say that I think Bev missed Pete's sarcasm in his post. Pete is a very subtle(not chicken, just subtle ;) ) kinda guy and he sometimes has a hard time expressing himself. We are working on that however and I'm happy to report that he has been doing well in his therapy and by the next optical convention he should be well on his way to a cure!...hehehe

As for the point of Bob's post....it's vewwy simple. Once the Gov't gets their hands into anything, it NEVER goes away. Never. Did I mention Never? Think of the old folks who would rise up and vote en masse if they could no longer get their free lens, one at a time after their surgery. It would be like taking away food stamps in the barrio. There might even be riots....looting of medical supply stores and no Luby's would be a safe place to eat. If you think about it along these lines then you understand that your government is only doing what's in YOUR best interest. They don't want tax-paying citizens to be harrassed by cane-toting septogenarians heck-bent on mayhem and anarchy. It's all for you the dear taxpayer, it's all for you.

Now on a serious note, I still make all of my medicare pt's file their own re-imbursement forms. But then again, I'm a jerk, ask anyone.

To quote Bev:
The psuedophake usually only recieves one pair of spectacles per eye done per lifetime because the bulk of expenditure occurs in the replacement of the crystalline lens with an IOL. This is ok to me because the eye has been returned for the most part to that of a presbyope with out the aging natural lens.
That last sentance says it all...let me quote ya again Bev "....the eye has been returned for the most part to that of a presbyope with out the aging natural lens"
If that's the case why aren't they paying for glasses for all presbyopes? (Oh heck, I hope this doesn't give them any ideas) They (read WE, the taxpayer) have already paid for the surgery to bring their vision back to that of a "normal" prebyope....why in the world should we then supplement their spectacle lenses as well?

Chad "that's MISTER Meanie to you" Huber

P.S. Please don't think that I don't have compassion for those poor old folks that didn't plan for their gold-plated years, I just happen to be one of those weird people that thinks Family, Churches, and the good will of most people should help them. Not the Gov't.

[This message has been edited by Chad Huber (edited 08-16-2000).]

**Bob Rihl** · 08-16-2000, 02:41 PM

Originally posted by Tammy:
Al,

I can honestly say that the paperwork is not a nightmare. I bill everyday for DME and as long as you follow the rules its a breeze. I have been doing this for 17 years and have seen all the changes, key word changes....you must always keep up and follow up....not to blow my own horn but follow-up is not that difficult when you have a competent MEDICAL biller.

Your friend in the billing department,

Tammy

p.s. hey bob I know a great biller if you need one.

Tammy:
Let me make myself more clear. First of all, I'm not calling for the elimination a medicare reinbursement for true Aphaics, the ones who had the old surgery where the glasses or contacts replace the lens of the eye. I'm calling for the elimination of Medicare paying for the first lens after surgery when an IMPLANT is the replacement for the lens of the eye, and the eyeglass lens is merely something that the patient would need anyhow, due to presbyopia, which is NOT normally a covered expense. Secondly, I HAVE a great billing clerk and since she's billing people for various things anyhow, it's not much more trouble for her to file te Medicare forms. I'm just saying that paying for a post-IOL lens is an abuse of the original intent of the system.
But as far as edicare itself is concerned, up until the past generation, MOST people paid for it without the aid of a federal government system. And as Chad said, those who couldn't afford it wer treated FREE by church run hospitals, county hospitals, etc. Medicare is not charity. We all pay bg money tat we can eceive it when we get old. It's an insurance business, and I am philosophically opposed to the federal ge ANY business, including the retirement annuity buisiness, Social Security. These are all thing that people should do for themselves. My parents and grandparents "saved up for their old age" EXPECTING that they would have medical expenses and no income after retirement. So have I. So should everybody. And for the truly poverty stricken and disabled, maybe their should be some government program, and I'm sure private charities would help out, too. I'm just tired of the government getting into EVERYTHING and like to point out abuses of their own system, which I don't like, whenever I can.
Independent Bob

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"Come see me now, heah?"

**Texas Ranger** · 08-16-2000, 05:32 PM

Y'all, Tammy, we are NOT a medicare provider, and do not accept Medicare payment for eyewear, but we do some pts post IOL glasses, they pay us, and we are required to file the claim for reinbursement for the pt. My secretary is tops and does a great job of billing, but it has nothing to do with "optical' and it is rediculous how many times forms are returned for "missing" information that "wasn't". Look, we got our money up front, we are just trying to help the pts get reimbursed. I'm glad you have such an efficient relationship with Medicare, just commenting that you may be an exception. I'm sure that they would prefer that beneficiaries go to "providers", so they can have more governmental control. BTW, in my market, Cole Vision has a monopoly on medicare administered, subsidized eyewear through an HMO Senior Plan, pts can go to Sears, Wards, Pearle, etc. and the HMO cuts a $125 check to Cole once a year toward their eyewear purchase, of course the pt. has to pay the retail difference, pretty hard to compete with that much subsidy. Supposedly, the HMO gets about $8K/yr.,per person to administer health care, so $125 of the $8K goes for glasses, these are post op patients, they're regular clients we've cared for for years. A lot of them come back though, with cheap, junk glasses that they can't see with and apologizing for going elsewhere, weird. So, medicare is paying for presbyopic glasses, just that the post IOL have to jump through hoops, and we get to do some of them, if we cross our T's.

**Texas Ranger** · 08-16-2000, 05:34 PM

P.S. it would solve problems and be fairly competitive if the HMO would give the pts a voucher worth $125 toward their glasses, if the Cole/HMO arrangement was up and up!

**Bev Heishman** · 08-17-2000, 08:06 AM

Chad,

Are you a Medicare participating provider? Or do you have your patients/clients submit on their own?

I said it is ok by me to recieve one pair post-operatively. It is not fair to other presbyopes because the eye has been restored to a more natural state. It is very difficult to be in a busy dispensary and inform one Medicare patient that this is available to them and the person at the next desk doesn't have the same benefit because they have not had surgery. I really disliked it when they got lenses and frames yearly. The elimination of this would be fine. Give it to seniors for prescription drugs.

I would rather recieve reimbursement for one or two pairs from this program than to recieve the low reimbursements from other 3rd parties for individuals of all ages. You also can still manufacture your lenses and increase your profit.

I did recognize Pete's sarcasm but that is Pete!

Bev

**Tammy** · 08-17-2000, 10:26 AM

I love this! Nobody has posted an insurance ? in months, here we go. Everyone has an opinion and is entitled, I can appreciate everyones feed back, and understand where everyone is coming from. But, the rules are there, and as providers of DME we must follow ALL the rules the government puts upon us, wether we like them or not. I still have to pay my darn taxes and then some, even though I don't like it, but then again I don't want to be looking thru the bars in that cold jail cell.

We may not like the rules, but, rules is rules, and I'm all about compliancy, no if ands or butts.

Always your friend in the billing department,

Tammy

**Pete Hanlin** · 08-17-2000, 10:46 AM

Bev,
You are right on about preferring Medicare's reimbursement one or two times vs. an HMO's miniscule reimbursements each year... Putting aside all the things I don't like about Medicare, I have to admit they usually pay better and more reliably than the other third party plans we accept (with the exception of BCBS, which is- in my opinion- the best major medical third party provider out there).

Bob has struck a chord with his musings on Medicare's continued coverage on post-op eyewear. I think the larger issue is that this is another example of a government program that doesn't end after it ceases to be useful. As Bob pointed out, a true aphake uses their eyewear to replace the missing lens- I can't remember the last time I saw an aphake here in the office.

Thanks for appreciating my cynical sense of sarcasm though ;) . Keep Pennsylvania beautiful til I get back!

Pete

**Bev Heishman** · 08-18-2000, 12:38 AM

I will always work on keeping this state beautiful and just when do think you will be returning? When I am old and gray?

Luv ya!

[This message has been edited by Bev Heishman (edited 08-17-2000).]

**Pete Hanlin** · 08-18-2000, 10:19 AM

I'm afraid the wife likes it too much here in the Sunshine State- although she did complain a lot about the heat this Summer... hmmm.

Florida does have its fine points: compared to Pennsylvania, there are far fewer taxes in Florida- and I don't need to point out that Opticians have a better atmosphere to work in down here. While I hate the Summers, Fall does last from October to March (and Fall is my favorite season). The cost of living is less expensive here (our heating bill used to run $300+/month in the Winter back home). Finally, I really enjoy my job.

All that said, though, the things I miss about Pennsylvania are the history and the culture. Florida is such a hodge-podge of Snow Birds (like me), Southerners (like my wife), and transients from around the country. Also, it doesn't have the "burgs" and "towns" of rural Pennsylvania.

Sorry for the dissertation on the finer points of Florida/Pennsylvania... I just always wax nostalgic for the good 'ole Keystone State!

Hoping you and "youns" the best, Bev.
Pennslyvania Pete
PS- Gimme Strausburg, Gettysburg, Valley Forge, and the Susquehanna any day over Orlanda, Miami, and the Chattahoochee!

**Bev Heishman** · 08-18-2000, 11:47 PM

I told you I would be old and gray...when are you coming to visit relatives in this great state?..the best state in the nation! We rival Florida with our population as you know!

I would love to see you even for 2 hours. You know that. We will keep politics out of the picture. What possessed you a Yankee Republican to marry a Southerner? I'm just kidding!

We have one great CEC convention scheduled in Lancaster in October. I'll be there.

We really need to be on a team panel again where we are in our finest form. Advanced Breathing 202. Kerosene smelling suitcases in a hotel lobby. I am surprised we weren't arrested. Darris and Chad thought the Big Easy was a trip!

On the subject of Orlando..thinking about a time share. Had a wonderful time there this summer.