Medicare fraud and how it can affect your cataract
While most doctors will prioritize patient care, the financial landscape of healthcare can sometimes blur lines. Cataract surgery, being one of the most commonly performed surgeries in the United States, can be a significant source of revenue for clinics and surgeons. Cataract surgery is the top procedure covered by Medicare/Medicaid. Dishonest surgeons may exploit this and provide medically unnecessary services.
Numerous studies have discovered that not everyone who’s recommended cataract surgery might actually need it. Take a look at these recent cases.
Just this year, the Department of Justice has investigated two > $1,000,000 frauds relating to medically unnecessary cataract surgeries.
First of All: What Exactly Is a Cataract?
Imagine your eye is a camera. Sometimes you have a clouded lens, and that’s what we call a cataract. Patients often describe that they feel like they’re trying to see through a foggy window where everything gets blurry. Driving at night feels like a challenge, while driving during the daytime feels like you’re exposed to bright lights. If a cataract makes it difficult for you to carry out your usual activities like reading road signs, your health care team may suggest cataract surgery. This eye surgery can often alleviate symptoms such as blurry vision, halos around bright lights, or double vision.
Any vision loss can be off-putting, especially if you experience cataracts in both eyes. Fortunately, eye surgeons can resolve cataracts by replacing your clouded, natural lens with an artificial lens. By comparison, macular degeneration, a frequently confused and incurable condition, causes dark spots to appear in the center of your vision.
What is cataract surgery and how is it performed?
Cataract surgery is a surgical procedure to remove the cloudy lens of the eye and replace it with a new artificial lens. The surgeon makes a small incision, breaks up the cataract using ultrasound or laser, and inserts the new lens.
As part of the informed consent process, cataract surgeons will discuss the potential lenses available and which will be most likely to generate a safe procedure.
When Do You Need Cataract Surgery?
Before we had precision tests, the process to undergo cataract surgery was very simple. If you described your vision as cloudy, your doctor would recommend the removal surgery. Thankfully, the process has improved to ensure patients aren’t rushing into this procedure.
Ophthalmology is one of the only medical fields where patients regularly exaggerate their symptoms in search of a medical operation. Sometimes, folks might exaggerate how bad their vision is, because they are hoping their insurance will cover related procedures. Thus, honest practitioners trying to avoid insurance fraud and provide high-quality care will have a high standard to recommend this treatment. As a result, doctors have quantitative ways to check.
How Cataract Surgeons Evaluate Your Need
Your ophthalmologist might determine that your symptoms are consistent with a cloudy lens of your eye. In that case, they have several tools at their disposal to evaluate your need. To start, they might ask you about everyday tasks like driving, pair it with some specialized tests, and even measure how dense or severe the cataract is.
When things are not clear-cut, they might use advanced imaging techniques or tools to get a better look. In the more extreme cases, the optometrist will evaluate your need through the combination of the visual acuity questionnaire. This includes evaluating your difficulty to drive, contrast sensitivity, and the actual measurement of the cataract’s densitometry, as well as the size and shape of your eye. Additionally, your doctor will try to choose an IOL that can allow you to see without glasses or contact lenses after surgery.
Identifying Unnecessary Cataract Surgery: Making Sure Everyone’s on the Same Page
In most cases, doctors want to ensure they’re making the right call. They might have you document your issues, like challenges with reading or driving. This way, they get a holistic view of what you’re experiencing and can compare it with their findings.
If you feel that your doctor is skipping steps and overlooking your concerns, you should look for a different optometrist. Always remember that it’s your vision on the line, and any surgery puts you at a risk of complications. You need to be comfortable with every step you take.
How to Get a Second Opinion
Seeking a second opinion isn’t doubting your doctor—it’s about double-checking. It’s always a good idea to have multiple viewpoints, as medical necessity isn’t always a clear score. Find a reputable specialist, share all your records, and chat openly about your concerns.
A trustworthy ophthalmologist won’t mind if you get a second opinion before having surgery. If they react poorly to your request, it’s most likely a sign you need to find a different provider. If both doctors recommend this procedure, you can go ahead with more confidence about your decision.
If you do decide that you need cataract removal surgery, you will likely undergo an outpatient procedure. Under Medicare, you’re covered for the operation if you get a standard artificial/intraocular lens (iol). With Medicaid, the coverage (even if medically necessary) depends on your state law.
Are There Non-Surgical Treatment Options?
If you don’t have pain or significant trouble with sight during your daily activities, you may not need to rush into surgery. Simple things like changing your prescription glasses, introducing eye drops, or tweaking your lifestyle could be the interim solution you need. However, cataract surgery is the only way to get rid of a cataract and sharpen your eyesight. Ask your provider what the expected outcome would be without surgery so you can decide if your quality of life will be acceptable without it.
In some cases, your doctor might also recommend surgery even if your cataracts aren’t the main cause of your vision problems. For example, you may need to have cataracts removed so your doctor can see into the back of your eye. This can help them track and treat other eye conditions, like diabetic retinopathy or age-related macular degeneration (AMD).
If My Vision Improves after the Procedure, Am I Safe?
The majority of the time, patients who select a reputable doctor will recover well from their surgery with good vision by following their doctor’s instructions and experience a quick return to daily life. However, some patients may develop a condition known as a secondary cataract, or posterior capsule opacification after cataract surgery. Secondary cataracts can appear weeks, months, or even years after your surgery. The good news is your eye doctor can fix them with laser treatment.
Conclusion
Trusting your healthcare professionals is important, especially when it comes to a critical concern like poor vision. That’s why it’s vital to be proactive about your choices and ensure you’ve selected a professional you can trust. Explore how our surgeon selection tool can help you here. By finding an experienced, honest cataract surgeon, you can feel comfortable knowing you’ve cut down on potential risks.