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 more damage. She is supposed to be checked regularly, she said.

During 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 looked up beforehand whether the clinic in nearby Madison participated in her 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 came.

The Medical Procedure

An optometrist tested Tuszynski’s vision and took pictures of her optic nerves.

The Final Bill

$340, which included $120 for vision testing and $100 for optic nerve imaging.

The Billing Problem: Vision Coverage vs. Medical Coverage

Tuszynski’s UnitedHealthcare Medicare Advantage plan declined to pay for her eye appointment. “The member has no out of network benefits,” the company’s denial letter said.

Tuszynski felt like she was seeing double. How could an eye doctor be in-network and out-of-network at the same time? She said she sent the insurer a screenshot of its own webpage showing the clinic listed as in-network.

She said that after she complained, UnitedHealthcare representatives explained that the eye clinic was in-network under her vision plan, so her policy would cover the clinic’s services related to glasses or contact lenses. But they said the clinic was not in-network for her medical insurance plan, and glaucoma treatment is considered a medical issue.

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

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

Sergel said she understood how a customer could mistakenly think vision insurance would cover all care for the eyes. She said UnitedHealthcare recommends that before undergoing treatment, patients ask care providers whether they are in-network for specific services.

Otherwise, she said, to know whether a test or treatment is covered by vision insurance, “you’d have to read the nitty-gritty” of a policy.

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

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

The federal government pays insurers to run Medicare Advantage plans for people who choose them instead of traditional Medicare. More than half of Medicare beneficiaries . Many offer routine vision and dental coverage that isn’t included with traditional Medicare.

“We hear from people who choose these plans because of those supplemental benefits, but there is not a lot of transparency around 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 to complain to federal officials. She also wrote to ºÚÁϳԹÏÍø News, which asked the insurer about the case.

UnitedHealthcare eventually 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 sound like that pleased her.”

Tuszynski confirmed that she is not pleased.

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

The Takeaway

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

In an ideal world, Schwarz said, Medicare would consider things like dental cleanings, eye checkups, and hearing aids as basic health care that would be covered in the same way as other medical care. But until that happens, she said, patients with any doubt should call their insurers beforehand to check whether services will be covered.

Tricia Neuman, a senior vice president with KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News, noted that Medicare’s website that can help people determine whether their doctors participate in a Medicare Advantage plan.

“This is helpful and a step forward, but 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 on their insurer.”

Tuszynski worked for 30 years as a secretary in hospitals and at doctors’ offices, so she’s familiar with billing issues, she said. “If I can’t sort through all this, how can anybody else do it?”

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

“I have a strong feeling about right and wrong — and this is just wrong,” she said.

For 2026, she decided to shift out of her Medicare Advantage plan. She now is enrolled in traditional Medicare, plus a supplemental plan to help with copays and other costs. She pays $184 a month for that plan, compared with paying 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 eyeglasses, just a discount plan if she buys glasses from certain stores. She used her Medicare Advantage insurance to buy new glasses shortly before switching. “Hopefully, those will last me a while,” she said.

Bill of the Month is a crowdsourced investigation by  and  that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? !

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Even Chloë, who was in kindergarten, had a good understanding of how things would go that day. Before the procedure, a hospital worker gave her a coloring book that explained the steps of the surgery — a procedure to correct a condition that could have eventually interfered with her vision.

“Chloë is very smart,” Jones said. “She reads at almost a third-grade level now, and she’s only 6.”

Jones did her homework, too. With no pediatric ophthalmologists near their home in Wentzville, Missouri, who would take their insurance, she asked the insurer to cover Chloë’s out-of-network care as if it were in-network. The insurer agreed to let her see an out-of-network specialist.

Chloë made it through surgery without a hitch. Jones said her daughter enjoyed a few popsicles at the hospital before going home.

“ I slept with her every night because she was so worried she would wake up and not be able to see,” she said. “But it healed beautifully, and she was absolutely ready to go back to school.”

Then the bill came. 

The Medical Procedure

Chloë was born with a droopy left eyelid, a condition known as ptosis. To correct the problem, an ophthalmologist surgically lifts the eyelid, preventing it from disrupting the patient’s line of sight.

Ophthalmologists, unlike optometrists and opticians, hold medical degrees and can provide advanced eye care, including surgery.

The Final Bill

$15,188, including $10,382 for the procedure and $2,730 for anesthesia. Initially, insurance paid just $1,775.79, leaving the Jones family owing $13,412.21 — until Chloë’s uncle, who had recently finished his term as a state senator, asked a colleague to look into it.

The Problem: Phantom Insurance Approval?

Months before Chloë inhaled bubblegum-scented anesthetic at Cardinal Glennon Children’s Hospital in St. Louis, Jones discovered that it can be hard to find a pediatric ophthalmologist. The doctor recommended by Chloë’s pediatrician wasn’t contracted with their insurer, UnitedHealthcare, and the closest in-network specialist was in Wisconsin, hundreds of miles away.

So Jones requested what’s called a network gap exception, under which the insurer would cover the recommended doctor’s services as in-network.

Before the surgery was scheduled, she received a letter saying UnitedHealthcare had approved her request “because currently there isn’t a doctor, health care professional, or facility in your area to provide these services.” The letter listed several medical billing codes for eye services and said they would be covered “at the network level.”

About a week later, the insurer sent a prior authorization letter approving Chloë’s surgery.

But UnitedHealthcare declined to pay most of the surgery bill, covering it as out-of-network. With approval letters in hand, Jones said, she did not understand why the insurer apparently was not honoring its agreement to cover her daughter’s treatment.

In fact, the similar-looking letters granted different kinds of approval.

UnitedHealthcare’s gap exception approved Chloë’s exams before the surgery as in-network. But in its prior authorization letter for her surgery with the same doctor, the insurer said only that it would cover it — without offering network discounts.

After receiving the bill, Jones contacted the insurer online, but she said a representative told her there was no record of its approval to cover the surgery as in-network.

“At that point, I didn’t even know what to do,” she said. “I’m like, ‘This is crazy.’”

She said she sent over a copy of one of the approval letters, which was on the company’s letterhead, but a representative told her the letter hadn’t come from UnitedHealthcare.

“They said, ‘You saw this surgeon, they’re not covered and you didn’t have permission, so, no, we’re not going to pay,’” Jones said, recounting the phone call.

An insurance representative told Jones she owed more than $13,000 because of “a balance billing issue.” That meant the Jones family would have to pay the $13,000-plus balance.

Spokespeople for UnitedHealthcare confirmed the company provided a gap exception and prior authorization for Chloë’s care. Eric Hausman, a spokesperson for UnitedHealth Group, said in a statement to ºÚÁϳԹÏÍø News that “we empathize with anyone who finds themselves in the unfortunate situation of being balance billed by an out-of-network provider for an amount significantly above market rates, and without any advance knowledge.”

Maryanne Wallace, a spokesperson for SSM Health, the health system that includes Cardinal Glennon Children’s Hospital, provided a statement that said SSM followed “standard patient billing procedures.”

“Occasionally, an insurance company may process a claim as an out-of-network service, which can result in a balance being billed to the patient,” the statement said.

The Resolution

Jones said she was blindsided by the big bill. She tried to fix the problem on her own, she said, keeping track of every interaction with the insurer and the hospital. She filed appeals with UnitedHealthcare.

Nothing helped — until she reached out to her brother Caleb Rowden, who had been a Missouri state senator for eight years after serving four years in the state House.

“ I’ve never used my brother’s political clout for anything,” she said. “I actually hate politics.”

Rowden told ºÚÁϳԹÏÍø News that he reached out to Travis Fitzwater, the state senator representing his niece’s district. Jones contacted Fitzwater’s office, too, and sent a complaint to Missouri Attorney General Andrew Bailey.

Fitzwater said his office did no more for Chloë than it would for any constituent.

“We’re not going to take a lot of credit for the result of it, because we didn’t ask for anything other than a resolution, so that everybody can be at peace and move on with their lives,” he said in an interview. “We just did what we do every day.”

After Fitzwater’s staff contacted the hospital and the insurer, representatives from both separately called Jones and notified her that UnitedHealthcare had paid the bill in full.

In the end, Chloë’s family paid nothing for her procedure — not even a copay.

The Takeaway

When it comes to insurance approvals, read the fine print carefully; “covered” does not mean an insurer will pay, let alone at in-network rates.

Rowden and Fitzwater said reaching out to your elected representative’s office can help. Advocating for constituents is part of their job.

“They usually have an open line of communication with these insurance companies and hospitals,” Rowden wrote in an email. “They may not always be able to get to a positive outcome since every situation is a little different, but they can usually get you to a next step.”

Jones is grateful that her brother was able to help, though she acknowledged that she probably would not have called him without a nudge from their mother. “I think I would still be fighting,” she said.

Bill of the Month is a crowdsourced investigation by ºÚÁϳԹÏÍø News and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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But after just four months behind bars, John Estin Davis walked free. President Donald Trump commuted Davis’ sentence in the last days of his first term. In a statement explaining the decision, that “no one suffered financially” from Davis’ crime.

In court, however, the Trump administration was saying something very different. As the president let him go, the Department of Justice alleged in a civil lawsuit that Davis and his company defrauded taxpayers out of tens of millions of dollars with excessive urine drug testing. The DOJ alleged that Comprehensive Pain Specialists made such a “staggering” sum from cups of pee that employees had given the testing a profit-minded nickname: “liquid gold.”

Davis and the company denied all allegations in court filings and settled the DOJ’s fraud lawsuit without any determination of liability. Davis declined to comment for this article.

Since returning to the White House, Trump has said he will target fraud in Medicare, Medicaid, and Social Security, and his Republican allies in Congress have made combating fraud a key argument in their plans to slash spending on Medicaid, which provides health care for millions of low-income and disabled Americans. During an address to Congress last month, Trump said his administration had found “” without citing any specific examples of fraud.

“Taken back a lot of that money,” Trump said. “We got it just in time.”

But Trump’s history of showing leniency to convicted fraudsters contrasts with his present-day crackdown. In his first and second terms, Trump has granted pardons or commutations to at least 68 people convicted of fraud crimes or of interfering with fraud investigations, according to a ºÚÁϳԹÏÍø News review of court and , DOJ press releases, and news reports. At least 13 of those fraudsters were convicted in cases involving more than $1.6 billion in fraudulent claims filed with Medicare and Medicaid, according to the Department of Justice.

And as one of the first actions of his second term, Trump responsible for rooting out fraud and waste in government.

“It sends a really bad message and really hurts DOJ efforts at creating deterrence,” said Jacob Elberg, a former assistant U.S. attorney and law professor at Seton Hall University in New Jersey. “In order to reduce health care fraud, you need people both to be afraid of getting in trouble, but also for people to believe in the legitimacy of the system.”

Elberg said considerable fraud in Medicare and Medicaid exists largely because the programs’ “pay-and-chase models” prioritize paying for patient care first and tracking down stolen dollars second. To prevent more fraud, the programs would likely need to be redesigned in ways that would be slower and more cumbersome for all patients, Elberg said.

Regardless, Elberg said the president’s claimed focus on fraud appears to be a pretext for slashing spending that has been legally appropriated by Congress. Trump has empowered the Elon Musk-led Department of Government Efficiency, which he established and named by executive order, to make , halting some medical research and aid programs in addition to cutting spending on climate change, transgender health, and diversity, equity, and inclusion programs.

“What’s been the focal point to date of the administration is not what anybody has ever referred to as health care fraud,” Elberg said. “There is a real blurring — a seemingly intentional blurring — between what is actually fraud and what is just spending that they are not in favor of.”

Jerry Martin, who served as a U.S. attorney for the Middle District of Tennessee under President Barack Obama and now represents health care fraud whistleblowers, also said Trump’s focus on fraud appeared to be “just a platform to attack things that they don’t agree with” rather than “a genuine desire to root out and combat fraud.”

Even so, Martin said some of his whistleblower clients have been emboldened.

“I’ve had clients repeat back to me ‘President Trump says fraud is a priority,’” Martin said. “People are listening to it. But I don’t know that what he’s saying translates into what they believe.”

The White House did not respond to requests for comment for this article.

A Billion-Dollar Fraud Case and Needless Eye Injections

Presidents enjoy the unique authority to erase federal convictions and prison sentences with pardons and commutations. In theory, the power is intended to be a final bulwark against injustice or overly harsh punishment. But many presidents have been accused of using the pardon power to reward powerful allies and close associates as they leave the White House.

Trump issued about 190 pardons and commutations in the final two months of his first term, including for some health care fraudsters convicted of schemes with astonishing costs.

For example, Trump granted a commutation to Philip Esformes, a Florida health care executive convicted in 2019 of a $1.3 billion Medicare and Medicaid fraud scheme. After he was sentenced, DOJ announced in a press release that “the man behind one of the biggest health care frauds in history will be spending 20 years in prison.” Trump freed him 14 months later.

Trump also granted a commutation to Salomon Melgen, a Florida eye doctor who was serving a 17-year prison sentence for defrauding Medicare of $42 million. Melgen falsely diagnosed patients with eye diseases, then gave them unnecessary care, including laser treatments and painful eye injections, according to DOJ and court documents.

“Salomon Melgen callously took advantage of patients who came to him fearing blindness,” said after Melgen was sentenced in 2018. “They received medically unreasonable and unnecessary tests and procedures that victimized his patients and the American taxpayer.”

DOJ: $70 Million Spent on ‘Excessive’ Urine Testing

Despite the flurry of pardons and commutations at the end of Trump’s first term, the leniency he showed Davis was unique. Davis was the only convicted health care fraudster to receive clemency while the Trump administration was simultaneously accusing him of more fraud.

As CEO of Comprehensive Pain Specialists from 2011 to 2017, Davis oversaw a rapid expansion to more than 60 locations across 12 states, according to .

He was indicted in 2018 for using his CEO position to refer Medicare patients in need of medical equipment to a conspirator in return for kickbacks paid through a shell company, according to court documents. He was convicted at trial in April 2019 of defrauding Medicare.

Three months later, the DOJ filed a fraud lawsuit against Davis and CPS that piggybacked on the claims of seven whistleblowers. The lawsuit alleged that CPS collected more than $70 million from federal insurance programs for urine drug testing, most of which was “excessive,” and that an audit of a sampling of the tests had found at least 93% “lacked medical necessity.”

Typically, government insurance programs pay for urine testing so pain clinics can verify that patients are taking their prescriptions properly and not abusing any other drugs, which could contribute to an overdose. Patients could be tested as little as once a year or as often as monthly depending on their level of risk, according to the DOJ lawsuit.

But Comprehensive Pain Specialists performed “myriad urine drug testing on virtually every CPS patient on virtually every visit” then conducted “at least 16 different types of tests” on each sample, and sometimes as many as 51, according to the lawsuit.

Trump commuted Davis’ sentence for his criminal conviction in January 2021 as the DOJ was finalizing a settlement in the civil lawsuit. The commutation was supported by country music star Luke Bryan, according to a White House statement.

Months later, with President Joe Biden in office, CPS and its owners agreed to repay $4.1 million — less than 10% of the damages sought in the suit — and the case was closed.

In the settlement, Davis agreed not to take any job where he would ever again bill Medicare or other federal health care programs. He was not required to personally repay anything.

Martin, who represented one of the whistleblowers who first raised allegations against Davis and CPS, said the leniency that Trump showed to him and other health care fraudsters may discourage DOJ employees from pursuing similar investigations during his second term.

“There are a lot of rank-and-file people who are operating at the lowest point in their professional careers, where they’ve seen a lot of their work essentially be water under the bridge,” Martin said. “That’s got to be really demoralizing.”

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The spouse hadn’t responded to calls from other employees at the Rocky Mountain Lions Eye Bank, he said. As Lopez recalled, his supervisor thought a friend’s personal number would have more success.

Lopez refused. “I went for a walk,” he said.

Even without Lopez’s help, the eye bank that procures corneas from deceased donors in Wyoming and Colorado eventually collected his friend’s corneas, Lopez said. Lopez, who had entered the field to help people, became increasingly disillusioned during his three years working with the eye bank, despite rising from a technician to the distribution manager, and ultimately quit.

Checking the “donor” box on a driver’s license application, people may picture their heart, kidneys, or other organs saving another person’s life should the worst happen.

They are less likely to consider that tissues — corneas, tendons, bone marrow, skin, bone — are also covered by that checked box. In fact, donated tissues are collected much more frequently than organs, and corneas are the in the U.S., with , according to the Eye Bank Association of America.

Organ and tissue donations are guided by different rules, with less transparency and what critics identify as more self-policing in the tissue donation industry. In Wyoming and Colorado, where the Rocky Mountain Lions Eye Bank estimates it collects eye tissue from about , that has contributed to a tense work environment resulting in damaged or wasted tissues due to accidents, four former eye bank employees say.

“I think there’s an urgent need for stricter oversight of the donation process in general, particularly for eye and tissue banks,” said Janell Lewis, who worked at the Rocky Mountain Lions Eye Bank for 12 years, managing public relations and overseeing fundraising before she quit in February 2023.

John Lohmeier, executive director of the Rocky Mountain Lions Eye Bank, declined to be interviewed for this article. In a prepared statement, he said he couldn’t comment on personnel matters or specific incidents raised by the former employees.

But generally, he wrote, “there are internal procedures that have been in place and continue to be followed to investigate and/or report any incident that would impact health and safety concerns.”

Lewis, Lopez, and two other former eye bank employees recalled one or more of the following problems during their time at Rocky Mountain Lions Eye Bank:

• Removal of eye tissue from the wrong body
• Damage or destruction of corneas due to improper removal
• Removal of corneas from a donor with a high-risk family history that could endanger a transplant recipient
• Lack of transparency about whether errors were being reported to federal agencies
• Pressuring and bullying of technicians
• High turnover and brief training of low-paid and inexperienced technicians

The Windshield of the Eye

The cornea is considered the . It is a clear dome that protects the eye from contaminants, maintains fluid balance, and filters light. Recipients of cornea donations typically need transplants because of trauma, infection, or that cause blindness or blurred or cloudy vision.

The Rocky Mountain Lions Eye Bank is one of about 60 eye banks operating in the U.S., in corneal transplants. New technicians often arrive at the eye bank untrained, sometimes with only a high school diploma, to perform the grim job of removing corneas from recently deceased corpses for about the same wages many fast-food workers earn.

But what eye bank technicians may lack in education and training, they generally make up for with a strong belief in the mission, according to the former employees. They said they joined the Rocky Mountain Lions Eye Bank because they wanted to help restore people’s sight.

The nonprofit employs about 70 people across Colorado and Wyoming, according to a submitted in 2023. Those records also show a net income of less than $1 million and more than $16 million in assets. Lohmeier was paid about $142,000.

Organs vs. Tissue

Organ donations fall under the purview of the Health Resources and Services Administration, and details performance and of organ procurement groups. Tissue donation is regulated by the Food and Drug Administration, as well as national industry groups, and tissue bank transactions, performance, and outcomes are not available to the public.

There’s no reason tissues and organs should be treated differently, said Robert Dickson, medical director for the Washtenaw County Tuberculosis Clinic in Michigan. A patient in his county died from a bone graft contaminated with tuberculosis just a couple of years after a contaminated bone graft .

He to the Wild West and called it a major public health concern.

“It’s fundamentally no different from an organ transplant. You’re taking tissue from one deceased patient and putting it into a living recipient. But it is not regulated and not tested as rigorously,” he said.

Marc Pearce, president and CEO of the American Association of Tissue Banks, said such cases are very rare.

“We don’t believe that we’ve proven ourselves to be not capable of regulating ourselves,” he said.

FDA officials disagree that the tissue industry is largely self-regulated, pointing to that require certain organizations to register with the agency and provide a list of human cells or tissues they recover, store, or distribute.

The rules set donor eligibility requirements, and the agency inspects tissue establishments, including eye banks, said spokesperson Carly Pflaum.

“The FDA has implemented a tiered risk-based approach for the regulation of human cell, tissue and cellular and tissue-based products,” Pflaum wrote.

ºÚÁϳԹÏÍø News and WyoFile months ago requested reports of adverse events associated with the Rocky Mountain Lions Eye Bank, but the FDA has yet to provide them. FDA dashboards show the eye bank since 2017, and inspections since at least 2009 in any official action.

The tissue industry is largely self-monitored and the performance of eye banks is tracked internally, whereas the federal government publishes for organ procurement groups. Health care providers are not required to report to the FDA adverse events resulting from tissue transplants.

Organ transplant providers are required to report safety events in recipients within 72 hours to the Organ Procurement and Transplantation Network, which operates under contract with the U.S. Department of Health and Human Services. That includes an organ going unused because it was delivered to the wrong location. They have 24 hours if, for example, the recipient gets an infection or disease that may have been from the new organ.

Other countries have public registries detailing the outcomes of corneal transplants, including Australia, the United Kingdom, and Sweden. A similar registry in the U.S. could help monitor outcomes for patients and identify adverse events from transplant procedures, eye doctors and researchers wrote in .

Tissue bank industry groups are responsible for much of the oversight of their dues-paying members. Transplanting surgeons may report adverse reactions to the tissue bank, which generally then conducts a review and submits a report to the FDA and the Eye Bank Association of America or the American Association of Tissue Banks.

Nearly all eye banks in the U.S. are members of the Eye Bank Association of America, which inspects member banks at least every three years as part of its accreditation process, but such inspection reports aren’t publicly available. Safety is paramount, association president Kevin Corcoran said, and the association’s medical standards require eye banks to request patient outcome information from transplanting surgeons a few months after surgery.

“We want to make sure we don’t have an eye bank that is slipping in their performance or failing to recover tissue,” he said. He declined to comment on any individual eye bank’s performance or release quality or transplantation data, complaints filed, or investigations undertaken.

No investigations have resulted in corrective action, he said, in the 13 years he has been at the association. The Rocky Mountain Lions Eye Bank is an accredited member of the association.

Balancing Mission and Stress

Several of the former employees were hesitant to speak about the Rocky Mountain Lions Eye Bank because they didn’t want to sully the reputation of an industry they believe is essential for improving people’s lives and honoring the wishes of the dead.

But they described a high-pressure environment that they said led to many of their colleagues leaving and errors that reduced the number of successful retrievals.

Mackenzie Urban started recovering corneas as a technician for the eye bank in 2019 after finishing her bachelor’s degree. She saw it as a temporary job as she applied for medical school. But within a year of recovering her first cornea, she said, enough employees had left that she became the senior recovery technician and was training others.

She used limes for the training, guiding her students on how to use a scalpel to remove the peel without nicking the fruit beneath. Success meant lifting the peel off the lime without any juice spilling out.

“If you’re stressed, you’re going to shake,” Urban said.

Outside factors can compound the challenges of performing the delicate procedure. Maybe the coroner had drawn fluid from beneath the cornea, making collection much trickier, she said. After a person has been dead for about 24 hours, the eyes tend to deflate to the point of uselessness, adding time pressure to collecting donations, Urban said.

Sometimes, Urban said, another technician would be working on a body simultaneously, so that the entire body was moving around while she was trying to do the delicate procedure.

Interactions with grieving families could be intense, too. Sometimes, families would hug her, thankful that something good would come of their loss. Other times, they were hostile, such as the time one relative of a potential donor told her to “Cut your own f* eyes out, you b****,” she recalled.

Urban appreciates the work the eye bank performs and doesn’t regret her time there. She said she respected that “they had a real commitment to serving the community and keeping prices low.” (It’s illegal to sell human body parts for transplant, but companies get reimbursed varying amounts for the expenses of harvesting, preparing, and shipping tissues.)

But the workplace culture made it untenable for her, she said. For example, Urban said, she was reprimanded and told that she needed to “buck up or get out” because she declined to harvest corneas from a person who died from an unknown cause. The body was purple from the neck down, covered in oozing blisters and with opaque flecks in the eyes, Urban said.

When Irish Eyes Are Smiling

The Rocky Mountain Lions Eye Bank has international contracts and ships corneas to Japan and the U.K., among other destinations. It became the exclusive eye tissue provider for Ireland when that country stopped collecting corneas over fears of transmitting mad cow disease. That means anyone who has received in the past two decades likely now sees thanks to a person who died in Colorado or Wyoming, according to the Irish Blood Transfusion Service.

Lohmeier, the eye bank CEO, said local needs are prioritized for donations, while international shipments help fulfill the eye bank’s mission and “ensure that all viable corneas are transplanted, giving the gift of restored sight.”

The U.S. is one of the few nations with a . FDA inspection reports confirmed that the Rocky Mountain Lions Eye Bank procures more tissue than its geographic area can use.

The demand for international orders contributed to the high-pressure environment, Lopez said.

Employee turnover and the stress of the job resulted in the collection of corneas of poor quality, Lewis said. Local hospitals inquired about why so many corneas weren’t being transplanted, she added.

The leading reason was recovery errors that damaged the tissue, Lewis said.

Lohmeier disagreed that there was a significant decline in corneas being placed. “We do not believe this description accurately reflects the state of corneal recovery and transplants,” he said.

Internal records showed that about half of recovered corneas in November 2022 had moderate to heavy stress. The Eye Bank Association of America does not have comparable national data. The closest figure it tracks is the proportion, among tissues that were prepared but not transplanted, that were unable to be transplanted because of damage during processing; in 2022, it was a quarter.

Ashi Moore, who used to lead the Rocky Mountain Lions Eye Bank’s quality assurance department, said she once filed a report to the FDA after a donor’s eye tissues were removed despite a family history indicating a high risk of Creutzfeldt-Jakob disease. The disease, which should have been disqualifying for donation purposes, is a fatal brain disorder that through infected tissue.

The issue was caught before the corneas could be placed in someone else’s eyes, but it should never have gotten to the point that the corneas were removed from the body, Moore said.

At least once, a technician retrieved corneas from the wrong body, according to Moore and other former employees. (The FDA was unable to provide records to confirm that report by publication.) Moore said she should have been told about the case of mistaken identity immediately but said she wasn’t made aware of it until after the eye bank’s leaders handled the situation themselves.

She said she couldn’t find evidence that the eye bank had reported the error to the FDA. It was one of the major reasons she decided to leave the organization, though she had derived a strong sense of purpose from working at the eye bank, she said.

When Lewis resigned, officials at the nonprofit eye bank offered her $5,000 to sign a severance agreement with a nondisparagement provision. She declined.

Lewis said she would like to see states hold tissue recovery agencies to the same standards as other organizations that handle corpses, such as hospitals, coroners, and funeral homes. And if they fail to meet those standards, they need to be held accountable to build public trust, she said.

Lewis’ and Lopez’s negative experiences with the eye bank had another consequence. Each decided they no longer wanted to be an organ or tissue donor.

“After witnessing and experiencing so many issues, I no longer feel comfortable with the potential of my family having to go through that when the time comes,” Lewis said.

WyoFile is an independent nonprofit news organization focused on Wyoming people, places, and policy.

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His clinics, Tarzana Treatment Centers, are among the early adopters of an AI-based system that promises to dramatically expand screening for diabetic retinopathy, the leading cause of blindness among working-age adults and a threat to many of the estimated 38 million Americans with diabetes.

“It’s been a godsend for us,” said Espinoza, the organization’s director of clinic operations, citing the benefits of a quick and easy screening that can be administered with little training and delivers immediate results.

His patients like it, too. Joseph Smith, who has Type 2 diabetes, recalled the cumbersome task of taking the bus to an eye specialist, getting his eyes dilated, and then waiting a week for results. “It was horrible,” he said. “Now, it takes minutes.”

Amid all the buzz around artificial intelligence in health care, the eye-exam technology is emerging as one of the first proven use cases of AI-based diagnostics in a clinical setting. While the FDA has approved hundreds of , adoption has been slow as vendors navigate the regulatory process, insurance coverage, technical obstacles, equity concerns, and challenges of integrating them into provider systems.

The eye exams show that the AI’s ability to provide immediate results, as well as the cost savings and convenience of not needing to make an extra appointment, can have big benefits for both patients and providers. Of about 700 eye exams conducted during the past year at Espinoza’s clinics, nearly one-quarter detected retinopathy, and patients were referred to a specialist for further care.

Diabetic retinopathy results when high blood sugar harms blood vessels in the retina. While managing a patient’s diabetes can often prevent the disease — and there are treatments for more advanced stages — doctors say regular screenings are crucial for catching symptoms early. An  in the U.S. have the disease.

The three companies with FDA-approved AI eye exams for diabetic retinopathy — Digital Diagnostics, based in Coralville, Iowa; Eyenuk of Woodland Hills, California; and Israeli software company AEYE Health — have sold systems to hundreds of practices nationwide. A few dozen companies have conducted research in the narrow field, and some have regulatory clearance in other countries, including .

, formerly Idx, received FDA approval for its system in 2018, following decades of research and a clinical trial involving 900 patients diagnosed with diabetes. It was the first fully autonomous AI system in any field of medicine, making its in medical history,” said Aaron Lee, a retina specialist and an associate professor at the University of Washington.

The system, used by Tarzana Treatment Centers, can be operated by someone with a high school degree and a few hours of training, and it takes just a few minutes to produce a diagnosis, without any eye dilation most of the time, said John Bertrand, CEO of Digital Diagnostics.

The setup can be placed in any dimly lit room, and patients place their face on the chin and forehead rests and stare into the camera while a technician takes images of each eye.

The American Diabetes Association recommends that people with Type 2 diabetes get screened every one to two years, yet only about 60% of people living with diabetes get yearly eye exams, said Robert Gabbay, the ADA’s chief scientific and medical officer. The rates can be for people with diabetes age 21 or younger.

In swaths of the U.S., a and ophthalmologists can make appointments hard to schedule, sometimes booking for months out. Plus, the barriers of traveling to an additional appointment to get their eyes dilated — which means time off work or school and securing transportation — can be particularly tricky for low-income patients, who also have a .

“Ninety percent of our patients are blue-collar,” said Espinoza of his Southern California clinics, which largely serve minority populations. “They don’t eat if they don’t work.”

One potential downside of not having a doctor do the screening is that the algorithm solely looks for diabetic retinopathy, so it could miss other concerning diseases, like choroidal melanoma, Lee said. The algorithms also generally “err on the side of caution” and over-refer patients.

But the technology has shown another big benefit: Follow-up after a positive result is three times as likely with the AI system, according to a by Stanford University.

That’s because of the “proximity of the message,” said David Myung, an associate professor of ophthalmology at the Byers Eye Institute at Stanford. When it’s delivered immediately, rather than weeks or even months later, it’s much more likely to be heard by the patient and acted upon.

Myung launched Stanford’s in 2020, originally focusing on telemedicine and then shifting to AI in its Bay Area clinics. That same year, the National Committee for Quality Assurance expanded its screening standard for diabetic retinopathy to include the AI systems.

Myung said it took about a year to sift through the Stanford health system’s cybersecurity and IT systems to integrate the new technology. There was also a learning curve, especially for taking quality photos that the AI can decipher, Myung said.

“Even with hitting our stride, there’s always something to improve,” he added.

The AI test has been bolstered by a reimbursement code from the Centers for Medicare & Medicaid Services, which can be difficult and time-consuming to obtain for breakthrough devices. But health care providers need that government approval to get reimbursement.

In 2021, CMS set the national payment rate for AI diabetic retinopathy screenings at $45.36 — quite a bit below the median privately negotiated rate of $127.81, according to a . Each company has a slightly different business model, but they generally charge providers subscription or licensing fees for their software.

The companies declined to share what they charge for their software. The cameras can and are either purchased separately or wrapped into the software subscription as a rental.

The greater compliance with screening recommendations that the machines make possible, along with a corresponding increase in referrals to specialists, makes it worthwhile, said Lindsie Buchholz, clinical informatics lead at Nebraska Medicine, which in mid-December began using Eyenuk’s system.

“It kind of helps the camera pay for itself,” she said.

Today, Digital Diagnostics’ system is in roughly 600 sites nationwide, according to the company. AEYE Health said its eye exam is used by “low hundreds” of U.S. providers. Eyenuk declined to share specifics about its reach.

The technology continues to advance, with clinical studies for additional cameras — including that can screen patients in the field — and looking at other eye diseases, . The innovations put ophthalmology alongside radiology, cardiology, and dermatology as specialties in which AI innovation is happening fast.

“They are going to come out in the near future — cameras that you can use in street medicine — and it’s going to help a lot of people,” said Espinoza.

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The office was already closed, but the whole eye care team was there waiting for me. One of them pricked my eyeballs with a sharp instrument, allowing the ocular fluid that had built up to drain. That relieved the pressure and restored my vision.

But it was the fourth vision-impairing pressure spike in nine days, and they feared it would happen again — heading into a weekend. So off I went to the emergency room, where I spent the night hooked up to an intravenous tube that delivered a powerful anti-swelling agent.

Later, when I told this story to friends and colleagues, some of them didn’t understand the importance of eye pressure, or even what it was. “I didn’t know they could measure blood pressure in your eyes,” one of them told me.

Most people consider their vision to be vitally important, yet many lack an understanding of some of the most serious eye diseases. A published in JAMA Ophthalmology, based on an online national poll, showed that nearly half of respondents feared losing their eyesight more than their memory, speech, hearing, or limbs. Yet many “were unaware of important eye diseases,” it found.

A study released in July, conducted by Wakefield Research for the nonprofit and , showed that one-quarter of adults deemed at risk for diseases of the retina, such as macular degeneration and diabetic retinopathy, had delayed seeking care for vision problems.

“There is significantly less of an emphasis placed on eye health than there is on general health,” says Rohit Varma, founding director of the at Hollywood Presbyterian Medical Center.

Because eye diseases can be painless and progress slowly, Varma says, “people get used to it, and as they age, they begin to feel, ‘Oh, this is a normal part of aging and it’s OK.’” If people felt severe pain, he says, they would go get care.

For many people, though, it’s not easy to get an eye exam or eye treatment. Millions are uninsured, others can’t afford their share of the cost, and many live in communities where eye doctors are scarce.

“Just because people know they need the care doesn’t necessarily mean they can afford it or that they have the access to it,” says Jeff Todd, CEO and president of Prevent Blindness.

Another challenge, reflecting the divide between eye care and general health care, is that medical insurance, except for children, often covers only eye care aimed at diagnosing or treating diseases. More health plans are covering routine eye exams these days, but that generally does not include the type of test used to determine eyeglass and contact lens prescriptions — or the cost of the lenses. You may need separate vision insurance for that. Ask your health plan what’s covered.

Since being diagnosed with glaucoma 15 years ago, I’ve had more pressure checks, eye exams, eyedrops, and laser surgeries than I can remember. I should know not to take my eyesight for granted. And yet, when my peepers were filling with that vision-threatening fog last March, I felt oddly sanguine.

It turned out that those serial pressure spikes were triggered by an adverse reaction to steroid-based eyedrops prescribed to me following cataract surgery. My ophthalmologist told me later that I had come “within hours” of losing my eyesight.

I hope my brush with blindness can help inspire people to be more conscious of their eyes.

Eyeglasses or contact lenses can make a huge difference in one’s quality of life by correcting , which affect 150 million Americans. But don’t ignore the risk of far more serious eye conditions that can sneak up on you. They are often manageable if caught early enough.

Glaucoma, which affects in the U.S., attacks peripheral vision first and can cause irreversible damage to the optic nerve. It runs in families and is among African Americans as in the general population.

in this country have diabetic retinopathy, a complication of diabetes in which blood vessels in the retina are damaged. And some age 40 and up have macular degeneration, a disease of the retina associated with aging that diminishes central vision over time.

The formation of cataracts, which cause cloudiness in the eye’s natural lens, is very common as people age: have them. Cataracts can cause blindness, but they are eminently treatable with surgery.

If you are over 40 and haven’t had a comprehensive eye exam in a while, or ever, put that on your to-do list. And get an exam at a younger age if you have diabetes, a family history of glaucoma, or if you are African American or part of another racial or ethnic for certain eye diseases.

And don’t forget children. can affect kids. Refractive errors, treatable with corrective lenses, can cause impairment later in life if they are not addressed early enough.

Healthful lifestyle choices also benefit your eyes. “Anything that helps your general health helps your vision,” says Andrew Iwach, a clinical spokesperson for the and executive director of the .

Minimize stress, get regular exercise, and eat a healthy diet. Also, quit smoking. It of major eye diseases.

And consider adopting habits that protect your eyes from injury: Wear sunglasses when you go outside, take regular breaks from your computer screen and cellphone, and wear goggles when working around the house or playing sports.

The offers information on virtually everything related to eye health, . Other good sources include the American Academy of Ophthalmology’s and the .

So read up and share what you’ve learned.

“When you get together for the holidays,” says Iwach, “if you aren’t sure what to talk about, talk about your eyes.”

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

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When Jerry Bilinski, a 67-year-old retired social worker, scheduled cataract surgery with Carolina Eye Associates near his home in Fayetteville, North Carolina, he expected no drama, just a future with better vision.

Cataract procedures are among the most common surgeries in the U.S. — take place annually — and generally take about 30 minutes under light sedation. At the same time, the surgeon scheduled the placement of a little stent inside Bilinski’s eye to relieve pressure from his diabetes-related glaucoma, also a routine procedure to preserve his eyesight.

Bilinski recalled being sedated during the surgery in May and hearing a nurse anesthetist ask him whether he felt any pain. Bilinski said no — only some pressure on the right side of his head. He said the nurse anesthetist responded that he would increase the sedation. Despite being under anesthesia, Bilinski knew something was wrong.

“The next thing I know there’s some sort of commotion going on, and I hear the doctor yelling at me, ‘Don’t move! Stay still!’ — yelling in my ear,” Bilinski said. “And then I hear the doctor say, ‘What’s that cut on his head?’”

It was a small abrasion — nothing serious, he said — but it went unmentioned by the staff. At home, he took a nap and awoke to blood on his pillow. Memories of the incident came flooding back.

His doctor mentioned nothing about the incident at his post-operative appointment, so Bilinski brought it up. “I said, ‘You know, doctor, I just have some questions for you because I have some memories of some things happening there,’” he said. “And at that point, I think she probably knew the jig was up and said, ‘Yeah, we had a little incident. You had a little adverse impact from the anesthesia.’”

The surgery was a success, and the cut on his forehead healed. But Bilinski wanted to know more about his reaction to the sedation. Later, when he got his medical records, they said the surgery had “no complications.”

“They hid it,” Bilinski said.

Then the bill came.

The Patient: Jerry Bilinski, 67, a retiree who has traditional Medicare and a supplemental Medicare plan through UnitedHealthcare.

Medical Service: Cataract removal and replacement of a lens, plus insertion of a Hydrus Microstent device to treat glaucoma.

Service Provider: Bilinski’s procedure was performed at the by Dr. Tarra Millender of Carolina Eye Associates, a chain of medical and surgical eye care centers headquartered in Southern Pines, North Carolina.

Total Bill: $1,805 for the doctor’s fee for cataract surgery and insertion of a stent. Bilinski’s portion of that bill was $54. In addition, Fayetteville Ambulatory charged Medicare $10,745 for the surgery. Medicare paid $2,377 to the surgery center, and Bilinski’s supplemental Medicare plan paid an additional $550. Bilinski owed $50 to the surgery center.

What Gives: Professional standards of care dictate that medical providers inform patients about injuries that happen during surgery. But what should happen next — whether that’s an apology or an offer to waive some portion of the bill — is an open question in the U.S. health care system. Another question: If the injury requires treatment — if, for example, Bilinski’s cut had needed stitches (it didn’t) — who should foot the bill?

T.J. McCaskill, chief operating officer for Carolina Eye Associates, declined an interview request, citing federal and state patient privacy laws, even though Bilinski gave permission for the details of his medical case to be released to a reporter. Millender, the doctor, did not return a reporter’s messages.

When patients experience adverse reactions during treatment, they are generally expected to pay the cost of bringing themselves back to good health. That might make sense if the reaction — such as an allergic reaction to a new antibiotic — could not have been anticipated. But what if the injuries are the result of negligence, carelessness, or a medical mishap (after all, providers are human and accidents happen)?

After reviewing details about Bilinski’s case, Arthur Caplan, a professor of bioethics at New York University’s Grossman School of Medicine in New York City, said he found the injury bizarre. He said he couldn’t understand why an adverse reaction to anesthesia would lead to a bloody forehead.

“That gash is pretty weird,” Caplan said. “If someone asked me to pay a bill on this, I would have said ‘no’ until we get this resolved.”

Caplan said a case like Bilinski’s would be unlikely to pose a legal risk for the provider; most attorneys will not accept a case in which any damage awards are likely to be small.

In some cases, doctors and medical offices do voluntarily give rebates to patients injured during treatment, Caplan said. A patient who experienced an infection at the site of an IV, for example, and needed a few extra days in the hospital for antibiotics might not be billed for the extra days.

“There is no standard policy,” he said. “That’s the doctor’s or medical practice’s decision.”

Resolution: The cut on his forehead healed, but Bilinski — who spent his career working in health care — felt he deserved to know what had caused the injury.

“If you make medical records that are not accurate, it puts people in danger,” he said. “In my case, it indicates that I had a certain anesthesia at a certain dosage, which in fact produced an adverse and potentially dangerous side effect, and that’s not in there. And instead it says everything went well and that I tolerated the procedure well.”

Bilinski said he talked with McCaskill, the executive from Carolina Eye Associates, but did not receive an apology or a satisfactory explanation.

Medicare, a government insurance program that typically serves seniors and people with disabilities, and a secondary insurance plan Bilinski carries through UnitedHealthcare covered most of the costs of the Medicare-negotiated rates for the surgery.

Bilinski owed his modest, predictable Medicare copays, as most enrollees do after surgical procedures. But Bilinski said he believes taxpayers were cheated because the handling of his injury was unprofessional and Medicare paid its full fee for a procedure during which something went awry.

He filed a complaint with the North Carolina Medical Board, which licenses physicians and investigates allegations of medical mistakes and wrongdoing. He also filed an affidavit with the Fayetteville Police Department. (A police representative told Bilinski it was a civil matter, not criminal, so not in the police department’s purview.)

A medical board spokesperson, Jean Fisher Brinkley, declined an interview request, saying the agency doesn’t publicly discuss ongoing investigations.

“How many other people has this kind of thing happened to?” Bilinski said.

The Takeaway: If you have questions about something unexpected that occurs during medical treatment, request a copy of your full record. In Bilinski’s case, his record said there were “no complications” with the procedure. That clearly was not quite true, Bilinski said.

Patients injured during a procedure can ask for a rebate or seek to have insurance copays waived, Caplan said. They can also file a complaint with a state medical board to try to find out what happened and whether professional standards were violated.

Medical care is often unpredictable, but if an avoidable injury happens, the patient should not necessarily have to pay for that to be remedied, Caplan said.

Patients are frequently left holding the bag for extended hospital stays and reparative treatments for events that are not their fault. They might have to stay in the hospital three extra nights, over a weekend, for example, because a social worker wasn’t available for discharge planning on Friday. If a defective joint implant is put into a knee, the costs of replacing it are often borne by the patient and the insurer. (Although a lawsuit might eventually lead to a full or partial reimbursement from the manufacturer, such cases typically take years to get to a judgment.)

Patients should fight back and refuse to pay such bills, Caplan advised. Likewise, doctors in such situations should be fully transparent about what occurred and why. Though some physicians may worry about the risk of a malpractice suit, studies have shown that , often extinguishes a patient’s ire. Such apologies are required by professional ethics, and in some states they are required by law, as well.

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But the former English professor said her 2019 surgery with Ophthalmology Consultants didn’t get her to 20/20 vision or fix her astigmatism — despite a $3,000 out-of-pocket charge for the astigmatism surgical upgrade. Green, 69, said she ended up feeling more like a dollar sign to the practice than a patient.

“You’re a cow among a herd as you just move from this station to this station to this station,” she said.

Ophthalmology Consultants is part of EyeCare Partners, one of the largest private equity-backed U.S. eye care groups. It is headquartered in St. Louis and counts some in its networks across 19 states. The group declined to comment.

Switzerland-based Partners Group bought EyeCare Partners in 2019 for . Another eye care giant, Texas-based , was formed in 2020 from Massachusetts-based Webster Equity Partners, a private equity firm, and now it it has 190 physicians across 18 states. Other private equity groups are building regional footprints with practices such as and . Acquisitions have escalated so much that private equity firms now are routinely selling practices to one another.

In the past decade, private equity groups have gone from taking over a handful of practices to working with as many as 8% of the nation’s ophthalmologists, said Dr. Robert E. Wiggins Jr., president of the .

They are scooping up eye care physician practices nationwide as money-making opportunities grow in medical eye care with the aging of the U.S. population. Private equity groups, backed by wealthy investors, buy up these practices — or unify them under franchise-like agreements — with the hopes of raising profit margins by cutting administrative costs or changing business strategies. They often then resell the practices at a higher price to the next bidder.

The profit potential for private equity investors is clear: Much like paying to upgrade plane seats to first class, patients can choose expensive add-ons for many eye procedures, such as cataract surgery. For example, doctors can use lasers instead of cutting eye lenses manually, offer multifocal eye lenses that can eliminate the need for glasses, or recommend the astigmatism fix that Green said she was sold. Often, patients pay out-of-pocket for those extras — a health care payday unconstrained by insurance reimbursement negotiations. And such services can take place in outpatient and stand-alone surgery centers, both of which can be more profitable than in a hospital setting.

The investments that private equity groups provide can help doctors market and expand their practices, as well as negotiate better prices for drugs and supplies, Wiggins said. But he warned that private equity companies’ quest to maximize profitability runs the risk of compromising patient care.

“The problems are accumulating and driving up prices,” added Aditi Sen, director of research and policy at the nonprofit , which provides data and analysis about the economics of health care.

, a health economist at Johns Hopkins University, and her colleagues analyzed private equity acquisitions in ophthalmology, gastroenterology, and dermatology and found that practices charged insurance an extra 20%, or an average of $71, more after the acquisition. Private equity-owned practices also saw a substantial rise in new patients and more frequent returns by old patients, according to their research, .

A KHN analysis also found that private equity firms are investing in the offices of doctors who prescribe at high rates two of the most common macular degeneration eye drugs, meaning the doctors are likely seeing high volumes of patients and thus are more profitable.

KHN analyzed the top 30 prescribers of the macular degeneration eye drugs Avastin and Lucentis in 2019 through a . Private equity companies went on to invest in 23% of the top Avastin prescribers, and 43% of the top Lucentis prescribers — far higher than the 8% of ophthalmologists in which private equity currently holds a stake. Retina Consultants of America, for example, has invested in the practices of four of the top Avastin prescribers, and nine of the top Lucentis prescribers.

“The private equity model is a model that focuses on profitability, and we know they are not selecting practices randomly,” Sen said.

She noted that the volume of patients would be attractive to private equity, as well as the idea of investing in practices utilizing expensive Lucentis prescriptions, which cost roughly $1,300 an injection. Furthermore, she said, after being acquired by private equity, doctors could potentially change their prescription habits from the cheaper Avastin that costs about $40 to Lucentis – improving the bottom line.

Retina Consultants of America did not respond to requests for comment.

Last summer, Craig Johnson, then 74, decided it was finally time to have cataract surgery to fix his deteriorating eyes. He decided to go to CVP Physicians in Cincinnati, calling it “the cream of the crop locally for having eye surgery” as they do “100 a day.” The practice was already part of a private equity investment but has since been acquired by another investor, behemoth EyeCare Partners, .

Johnson, while happy with the results of his surgery, did not know about the manual cutting version of the surgery — the cheaper but just as effective alternative to using a laser. Johnson was using private insurance because he was still working, and he said that resulted in over $2,000 out-of-pocket charges for each eye. Laser surgery typically costs more than manual and , according to the American Academy of Ophthalmology.

Johnson explained that a salesperson, as well as a physician, walked him through options to improve his eyesight.

“Seniors are a vulnerable population because they’re on a fixed income, they’re a little older, they trust you … you’re wearing a white coat,” said Dr. Arvind Saini, an ophthalmologist who runs in California’s San Diego County.

Many patients have no idea whether private equity investors have a stake in the practices they choose because they are often referred to them by another doctor or are having an eye emergency.

David Zielenziger, 70, felt lucky to get a quick appointment at one of Vitreoretinal Consultants of NY’s practices after his retina detached. Zielenziger, a former business journalist, didn’t know it was associated with Retina Consultants of America. He loved his doctor and had no complaints about the emergency care he received — and continued to go there for follow-ups. Medicare covered just about everything, he said.

“It’s a very busy practice,” he said, noting that it has expanded to more locations, which must be making the investors happy.

In 2018, Michael Kroin co-founded , a group that helps doctors sell their practices to private equity firms, to capitalize on the explosion of interest. Eye care is one of the largest areas of investment, he said, because the specialty health care services apply to such a broad market of people.

Sixteen of the 25 private equity firms identified by industry tracker PitchBook as the biggest health care investors have bought stakes in optometry and ophthalmology practices, a KHN analysis found.

Kroin expects private equity investment in practices will only continue to accelerate because of competition from the “1,000-pound gorilla” of hospitals that also are acquiring practices and as the bureaucracy of insurance reimbursement forces more physicians to seek outside help. “If you’re not growing, it’s going to be tough to survive and make a similar level of income as you had historically,” he said.

Some health care experts worry that private equity companies could eventually be left holding an overly leveraged bag if other firms don’t want to buy the practices they’ve invested in, which could lead to the closures of those practices and ultimately even more consolidation.

“I’m not sure that most physician practices are so inefficient that you can get 20% more profit out of them,” said Dr. , chief of the division of health policy and economics at Weill Cornell Medicine’s Department of Population Health Sciences. And, he said, investors count on reselling to a buyer who will pay more than what they paid. “If that doesn’t work, the whole thing unravels.”

KHN investigative reporter Fred Schulte contributed to this article.

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But the partnership that began more than 30 years ago has fractured. Medi-Cal enrollees, many of whom are children, and their eye care providers say that they often wait months for the glasses and that sometimes they arrive broken.

“I understand the aim of trying to give prisoners a worthy occupation,” said , senior managing director of health and research for a California-based child advocacy group, Children Now. “But not at the expense of kids being able to see.”

Medi-Cal’s contract with the , or CALPIA, a business enterprise within the California Department of Corrections and Rehabilitation that employs inmates, has been in place since 1988. Other Medicaid programs — including those in Massachusetts and North Carolina — rely on prison labor to fulfill the promises of their vision benefit.

Experts noted, though, that such innovations work only if patients receive their glasses in a timely manner. Complaints from consumers and eye professionals have led California lawmakers to consider an expensive proposal that would allow Medi-Cal to purchase glasses from retail labs.

San Francisco resident Jane Angel said her 6-year-old son, David Morando, waited two months for his glasses to be delivered. He needed them because “he sits in the back of his classroom,” Angel said. She’s concerned because David is also on the autism spectrum, so not being able to see is another reason that concentrating in class is hard for him. “He’s not able to see the board, and it’s just hard for him to learn,” Angel said.

Optometrists, too, have been frustrated by slow turnaround times and frequent prescription mistakes.

“There’s nothing that we can do to get the glasses quicker,” said Joy Grey, the office manager of Alpert Eye Care in Mission Viejo. Her clinic tracks pending glasses orders by keeping empty trays for each on a shelf. A few months ago, so many CALPIA orders were pending that Grey and her colleagues were running out of space for others. “That’s how backlogged we are,” she said.

A — including 40% of the state’s children, nearly 5.2 million kids — are enrolled in Medi-Cal. The federal government requires that Medicaid offer vision benefits for children. Medi-Cal has generally covered routine eye exams and a pair of glasses once every two years for this age group. In January 2020, California’s program expanded benefits to adults.

Orders for glasses from Medi-Cal to CALPIA rose from nearly 490,000 in 2019 to 654,000 in 2020 and then to 880,400 in 2021.

Medi-Cal pays CALPIA about $19.60 for every pair of glasses made, said Katharine Weir-Ebster, a spokesperson for the .

In an of 171 of its members in March, the California Optometric Association found that 65% of respondents had experienced waits of one to three months for glasses ordered for Medi-Cal patients. In comparison, the survey found that the average turnaround time for glasses from private labs was less than 15 days.

But CALPIA spokesperson Michele Kane said production has been moving much faster than that. She said orders from 2011 to 2020 were filled, on average, five days after labs received them, but turnaround times began to slip during the covid-19 pandemic and hit a peak in January 2021 with a 37-day average. Since then, she added, the wait times for orders have improved and reached nine days by April 2021 and are expected to get back to five days this month.

To speed up fulfillment of Medi-Cal glasses orders, Kane said, CALPIA contracts with nine “backup” labs. Five are in states outside California. Of the 880,400 orders CALPIA received last year, 54% were sent to the contracted private labs, Kane said. These labs send the glasses to CALPIA, which then mails them to the clinics that ordered them.

Kane blamed prison lockdowns and restrictions triggered by the covid pandemic for exacerbating what she said were previously system hiccups that could upend production in prison optical labs.

In the survey, however, more than half of the optometrists said they had not seen turnaround times improve significantly.

A by the California legislature seeks to address the issue by stripping away the exclusivity of the arrangement and allowing clinics to also order glasses from retail labs.

The measure is a “response to the shocking disparity in the level of optical care that the state provides to some of its most vulnerable residents,” (R-Santa Clarita), the bill’s sponsor, said in a written statement.

But it has a big price tag. An analysis by California’s Department of Health Care Services, which was referenced by lawmakers supporting the bill, estimates that the cost to Medi-Cal for a pair of glasses from private labs would be than what it pays CALPIA.

CALPIA employs 295 incarcerated people for optical programs in three prisons: Valley State Prison in Chowchilla; the California State Prison Solano in Vacaville; and, most recently, the Central California Women’s Facility in Chowchilla. When the optometric program at the women’s facility is in full operation, expected this month, that total will be 420.

One benefit of the partnership is that inmates learn skills they can use to get jobs after they complete their sentences. It also works to lower recidivism rates, Kane said.

Anthony Martinez, 40, knows the pros and cons of the system. He was incarcerated in 2000 at age 19. For the last three years of his decadelong sentence, he worked in the prison’s optical program. “That was an opportunity that I was going to take full advantage of,” Martinez said.

The day after his release, Martinez got a license from the American Board of Opticianry to manufacture and sell glasses. A month later, he was hired as a lab technician at a LensCrafters in Los Angeles and was eventually promoted to lab manager. By 2020, he had helped open three other eyeglasses stores across the state.

Martinez is aware of the benefits he gained from his experience in CALPIA’s optical program but understands the impact that long wait times have on patients, especially kids.

“I would think that it needs to be run better,” Martinez said. “I mean, being out there, I understand you have to have quality and precision for this kind of work.”

, a pediatric optometrist at the University of California-San Francisco, said that in addition to experiencing long turnaround times, she has received many glasses for Medi-Cal patients that were broken.

Kane said CALPIA must remake fewer than 1% of orders.

Clarice Waterfield, 64, who lives in Paso Robles, had trouble with her order.

Waterfield has diplopia, or double vision, and an astigmatism that causes her vision to be blurry. She’s a personal shopper for grocery delivery company Instacart, and without help seeing, she said, boxes of cereal and crackers blend together. Grocery store aisles become big, long blocks.

She got her glasses about six weeks after ordering them March 1. She eagerly put them on but found they weren’t the right prescription. They made her vision worse. “You could have held a stuffed animal or something right in front of my face, and all I could see was a big, blurry smear.”

The clinic had to return the glasses and reorder them. After another six weeks, Waterfield received the correct pair. But she remembers the frustration.

“I was like, ‘Are you kidding me?’” Waterfield recalled. “I’ve been waiting too long for these glasses, and now that I have them in my hands, I have to hand them back?”

This story was produced by  (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at  (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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The 73-year-old retired orthopedic surgeon in Fresno, California, knew it was time for cataract surgery. “It’s like car tires wearing out because you drive on them so much,” he said.

In December 2021, he went to the outpatient department of the local hospital to undergo the common procedure that usually replaces the natural eye lens with an artificial one and is designed to restore vision. The outpatient procedure went smoothly, and Manimtim healed over the next few weeks.

Manimtim, who since retiring took a job evaluating disability claims for the state of California, knows the health care system and keeps tabs on his health benefits. He knew he already had met his health insurance deductible for the year, so he expected a manageable out-of-pocket expense for the surgery. He calculated his coinsurance would be about $750.

Then the bills came.

Patient: Danilo Manimtim, 73, of Fresno, California. He is insured through his employer by Anthem Blue Cross of California for outpatient care and is covered by .

Total Bill: Overall, the charges were $9,084 for surgery, anesthesia, medical supplies, pharmacy, and clinical laboratory services. Anthem paid $5,027 and initially billed Manimtim $4,057.

Service Providers: . It is part of Trinity Health, with 88 hospitals and 125 urgent care centers . The hospital system brought in nearly in revenue for the most .

Medical Service: Cataract surgery as an outpatient, involving anesthesia.

What Gives: Manimtim’s big bill stems from a simple decision that turned out to be a pitfall in the nation’s complicated health care system: He scheduled his surgery at a nearby hospital — a hospital that happened to charge about $7,000 more for the procedure than his insurer would pay.

Manimtim has proof that it could have been different right under his own roof: Four months later, his wife, Marilou Manimtim, 66, got the exact same procedure at an outpatient eye care surgical center in Fresno called . It is a half-mile from Saint Agnes Medical Center but is not affiliated with the hospital.

Both patients have the same insurance coverage through Anthem Blue Cross of California; they had identical cataract surgeries; and both providers were in Anthem’s coverage network. Marilou owed $204, while Danilo was on the hook for a staggering $4,057.

“This is ridiculous, and it feels very unfair,” Danilo Manimtim said. “How can it be so much more expensive than the surgical center? It’s walking distance away, and if I would have gone there, I would have saved myself a lot of money.”

Manimtim’s insurance plan, via his employer, the California Public Employees’ Retirement System, caps payment for outpatient cataract surgery at $2,000, according to Anthem. CalPERS instituted a , in which it determines a reasonable price for a high-quality procedure of that type in California. It then reimburses only up to that amount, encouraging patients to shop for treatment priced under the bar. For the cataract surgery itself, patients in Manimtim’s plan are on the hook for any charges above $2,000.

Even for hospital-based care, Saint Agnes’ overall charges are high for cataract surgery, said Dr. , chief medical officer for , which analyzes health care prices for employers. “The hospital charged three to four times the amount of what this surgery typically costs, which is around $3,000.”

“Nobody gets $9,000 for cataract surgery,” he added.

If Manimtim had opted for Medicare Part B, the part of the Medicare program that covers outpatient care, he likely would have been on the hook for only , a Medicare cost comparison tool shows. Medicare pays a set amount for procedures regardless of where they are performed.

But like many older Americans who are still working, Manimtim chose not to sign up for that coverage, instead opting for his employer’s plan because his monthly premium would be significantly cheaper.

Health care prices often have very little to do with the actual costs of providing the care and its quality — and patients often face the “double whammy” of high prices and complex benefits, said Anthony Wright, executive director of Health Access California, a nonprofit advocacy group. Too often, patients are on their own to figure out high prices and complex benefits, he said.

“You wonder what is the rationale for any of the prices in our health care system,” Wright said.

Resolution: After inquiries by KHN, Anthem contacted the hospital, Saint Agnes, seeking help for Manimtim. Although the doctor is responsible for requesting an exemption from CalPERS’ $2,000 limit on payments for cataract surgery under Manimtim’s plan, that didn’t happen before his surgery. Anthem asked the hospital and doctor to consider the request post-surgery, said Anthem spokesperson Michael Bowman.

Saint Agnes spokesperson Kelley Sanchez told KHN that the hospital and provider later requested the exemption that would allow the insurer to pay more than the $2,000 limit and that it was ultimately approved by Anthem. That is expected to leave Manimtim with a much smaller coinsurance bill, around $750 — and get him off the hook for being taken to collections by the hospital. The hospital will receive a higher payment from Anthem, which will cover a large portion of the remaining $4,057 bill.

And that high payment, like all high payments, contributes to rising health insurance payments for all.

Sanchez said the hospital isn’t in the price-gouging business but noted that hospitals generally have higher costs and tend to charge more than outpatient facilities.

“We never want to cause harm or create hardship for our patients, and that extends to our billing practices,” Sanchez said in a prepared statement.

She noted that Saint Agnes has financial assistance programs available and encourages patients to ask questions and understand potential costs before seeking care. “Every patient’s insurance plan is unique so it is their responsibility to understand their plan benefits,” she wrote. “It’s still complicated and we recognize that, and will continue to work toward greater price transparency.”

The Takeaway: The bottom line for patients, experts say, is to be sure to read the fine print of insurance coverage plans to understand all out-of-pocket responsibilities, including premiums, deductibles, copays, and coinsurance. Also, a small number of large employers that self-insure are , putting caps on what they’ll pay for common procedures. Shop around, and ask about prices on the front end if possible.

“People often focus on premiums because they are easy to compare, but premiums don’t tell the full story, and this example illustrates the trade-offs,” said Tricia Neuman, .

Anthem spokesperson Bowman urged patients to use the online Anthem “” to compare patient costs and find a cheaper option if one is available. Had Manimtim done that, he might have seen that getting his cataract surgery at an outpatient surgical center would have been much cheaper. But the details of provider cost and insurance coverage can be idiosyncratic and are often not displayed in a patient-friendly manner. Manimtim did try to explore his benefits before the procedure, he said, but did not get a clear answer from the insurer or hospital.

Manimtim also had advice for consumers: If you receive a medical bill and don’t understand the charges, don’t pay right away. Instead, call your provider and insurer to ask about the charges and whether there are ways to lower your bill.

“People need to be more informed by the insurance companies and hospitals about what options they have, to prevent overbilling,” Manimtim said. “A lot of people don’t know this could happen to them.”

Stephanie O’Neill contributed the audio portrait with this story.

Bill of the Month is a crowdsourced investigation by KHN and that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

This story was produced by , which publishes , an editorially independent service of the .

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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 more damage. She is supposed to be checked regularly, she said.

During 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 looked up beforehand whether the clinic in nearby Madison participated in her 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 came.

The Medical Procedure

An optometrist tested Tuszynski’s vision and took pictures of her optic nerves.

The Final Bill

$340, which included $120 for vision testing and $100 for optic nerve imaging.

The Billing Problem: Vision Coverage vs. Medical Coverage

Tuszynski’s UnitedHealthcare Medicare Advantage plan declined to pay for her eye appointment. “The member has no out of network benefits,” the company’s denial letter said.

Tuszynski felt like she was seeing double. How could an eye doctor be in-network and out-of-network at the same time? She said she sent the insurer a screenshot of its own webpage showing the clinic listed as in-network.

She said that after she complained, UnitedHealthcare representatives explained that the eye clinic was in-network under her vision plan, so her policy would cover the clinic’s services related to glasses or contact lenses. But they said the clinic was not in-network for her medical insurance plan, and glaucoma treatment is considered a medical issue.

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

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

Sergel said she understood how a customer could mistakenly think vision insurance would cover all care for the eyes. She said UnitedHealthcare recommends that before undergoing treatment, patients ask care providers whether they are in-network for specific services.

Otherwise, she said, to know whether a test or treatment is covered by vision insurance, “you’d have to read the nitty-gritty” of a policy.

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

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

The federal government pays insurers to run Medicare Advantage plans for people who choose them instead of traditional Medicare. More than half of Medicare beneficiaries . Many offer routine vision and dental coverage that isn’t included with traditional Medicare.

“We hear from people who choose these plans because of those supplemental benefits, but there is not a lot of transparency around 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 to complain to federal officials. She also wrote to ºÚÁϳԹÏÍø News, which asked the insurer about the case.

UnitedHealthcare eventually 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 sound like that pleased her.”

Tuszynski confirmed that she is not pleased.

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

The Takeaway

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

In an ideal world, Schwarz said, Medicare would consider things like dental cleanings, eye checkups, and hearing aids as basic health care that would be covered in the same way as other medical care. But until that happens, she said, patients with any doubt should call their insurers beforehand to check whether services will be covered.

Tricia Neuman, a senior vice president with KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News, noted that Medicare’s website that can help people determine whether their doctors participate in a Medicare Advantage plan.

“This is helpful and a step forward, but 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 on their insurer.”

Tuszynski worked for 30 years as a secretary in hospitals and at doctors’ offices, so she’s familiar with billing issues, she said. “If I can’t sort through all this, how can anybody else do it?”

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

“I have a strong feeling about right and wrong — and this is just wrong,” she said.

For 2026, she decided to shift out of her Medicare Advantage plan. She now is enrolled in traditional Medicare, plus a supplemental plan to help with copays and other costs. She pays $184 a month for that plan, compared with paying 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 eyeglasses, just a discount plan if she buys glasses from certain stores. She used her Medicare Advantage insurance to buy new glasses shortly before switching. “Hopefully, those will last me a while,” she said.

Bill of the Month is a crowdsourced investigation by  and  that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? !

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Even Chloë, who was in kindergarten, had a good understanding of how things would go that day. Before the procedure, a hospital worker gave her a coloring book that explained the steps of the surgery — a procedure to correct a condition that could have eventually interfered with her vision.

“Chloë is very smart,” Jones said. “She reads at almost a third-grade level now, and she’s only 6.”

Jones did her homework, too. With no pediatric ophthalmologists near their home in Wentzville, Missouri, who would take their insurance, she asked the insurer to cover Chloë’s out-of-network care as if it were in-network. The insurer agreed to let her see an out-of-network specialist.

Chloë made it through surgery without a hitch. Jones said her daughter enjoyed a few popsicles at the hospital before going home.

“ I slept with her every night because she was so worried she would wake up and not be able to see,” she said. “But it healed beautifully, and she was absolutely ready to go back to school.”

Then the bill came. 

The Medical Procedure

Chloë was born with a droopy left eyelid, a condition known as ptosis. To correct the problem, an ophthalmologist surgically lifts the eyelid, preventing it from disrupting the patient’s line of sight.

Ophthalmologists, unlike optometrists and opticians, hold medical degrees and can provide advanced eye care, including surgery.

The Final Bill

$15,188, including $10,382 for the procedure and $2,730 for anesthesia. Initially, insurance paid just $1,775.79, leaving the Jones family owing $13,412.21 — until Chloë’s uncle, who had recently finished his term as a state senator, asked a colleague to look into it.

The Problem: Phantom Insurance Approval?

Months before Chloë inhaled bubblegum-scented anesthetic at Cardinal Glennon Children’s Hospital in St. Louis, Jones discovered that it can be hard to find a pediatric ophthalmologist. The doctor recommended by Chloë’s pediatrician wasn’t contracted with their insurer, UnitedHealthcare, and the closest in-network specialist was in Wisconsin, hundreds of miles away.

So Jones requested what’s called a network gap exception, under which the insurer would cover the recommended doctor’s services as in-network.

Before the surgery was scheduled, she received a letter saying UnitedHealthcare had approved her request “because currently there isn’t a doctor, health care professional, or facility in your area to provide these services.” The letter listed several medical billing codes for eye services and said they would be covered “at the network level.”

About a week later, the insurer sent a prior authorization letter approving Chloë’s surgery.

But UnitedHealthcare declined to pay most of the surgery bill, covering it as out-of-network. With approval letters in hand, Jones said, she did not understand why the insurer apparently was not honoring its agreement to cover her daughter’s treatment.

In fact, the similar-looking letters granted different kinds of approval.

UnitedHealthcare’s gap exception approved Chloë’s exams before the surgery as in-network. But in its prior authorization letter for her surgery with the same doctor, the insurer said only that it would cover it — without offering network discounts.

After receiving the bill, Jones contacted the insurer online, but she said a representative told her there was no record of its approval to cover the surgery as in-network.

“At that point, I didn’t even know what to do,” she said. “I’m like, ‘This is crazy.’”

She said she sent over a copy of one of the approval letters, which was on the company’s letterhead, but a representative told her the letter hadn’t come from UnitedHealthcare.

“They said, ‘You saw this surgeon, they’re not covered and you didn’t have permission, so, no, we’re not going to pay,’” Jones said, recounting the phone call.

An insurance representative told Jones she owed more than $13,000 because of “a balance billing issue.” That meant the Jones family would have to pay the $13,000-plus balance.

Spokespeople for UnitedHealthcare confirmed the company provided a gap exception and prior authorization for Chloë’s care. Eric Hausman, a spokesperson for UnitedHealth Group, said in a statement to ºÚÁϳԹÏÍø News that “we empathize with anyone who finds themselves in the unfortunate situation of being balance billed by an out-of-network provider for an amount significantly above market rates, and without any advance knowledge.”

Maryanne Wallace, a spokesperson for SSM Health, the health system that includes Cardinal Glennon Children’s Hospital, provided a statement that said SSM followed “standard patient billing procedures.”

“Occasionally, an insurance company may process a claim as an out-of-network service, which can result in a balance being billed to the patient,” the statement said.

The Resolution

Jones said she was blindsided by the big bill. She tried to fix the problem on her own, she said, keeping track of every interaction with the insurer and the hospital. She filed appeals with UnitedHealthcare.

Nothing helped — until she reached out to her brother Caleb Rowden, who had been a Missouri state senator for eight years after serving four years in the state House.

“ I’ve never used my brother’s political clout for anything,” she said. “I actually hate politics.”

Rowden told ºÚÁϳԹÏÍø News that he reached out to Travis Fitzwater, the state senator representing his niece’s district. Jones contacted Fitzwater’s office, too, and sent a complaint to Missouri Attorney General Andrew Bailey.

Fitzwater said his office did no more for Chloë than it would for any constituent.

“We’re not going to take a lot of credit for the result of it, because we didn’t ask for anything other than a resolution, so that everybody can be at peace and move on with their lives,” he said in an interview. “We just did what we do every day.”

After Fitzwater’s staff contacted the hospital and the insurer, representatives from both separately called Jones and notified her that UnitedHealthcare had paid the bill in full.

In the end, Chloë’s family paid nothing for her procedure — not even a copay.

The Takeaway

When it comes to insurance approvals, read the fine print carefully; “covered” does not mean an insurer will pay, let alone at in-network rates.

Rowden and Fitzwater said reaching out to your elected representative’s office can help. Advocating for constituents is part of their job.

“They usually have an open line of communication with these insurance companies and hospitals,” Rowden wrote in an email. “They may not always be able to get to a positive outcome since every situation is a little different, but they can usually get you to a next step.”

Jones is grateful that her brother was able to help, though she acknowledged that she probably would not have called him without a nudge from their mother. “I think I would still be fighting,” she said.

Bill of the Month is a crowdsourced investigation by ºÚÁϳԹÏÍø News and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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But after just four months behind bars, John Estin Davis walked free. President Donald Trump commuted Davis’ sentence in the last days of his first term. In a statement explaining the decision, that “no one suffered financially” from Davis’ crime.

In court, however, the Trump administration was saying something very different. As the president let him go, the Department of Justice alleged in a civil lawsuit that Davis and his company defrauded taxpayers out of tens of millions of dollars with excessive urine drug testing. The DOJ alleged that Comprehensive Pain Specialists made such a “staggering” sum from cups of pee that employees had given the testing a profit-minded nickname: “liquid gold.”

Davis and the company denied all allegations in court filings and settled the DOJ’s fraud lawsuit without any determination of liability. Davis declined to comment for this article.

Since returning to the White House, Trump has said he will target fraud in Medicare, Medicaid, and Social Security, and his Republican allies in Congress have made combating fraud a key argument in their plans to slash spending on Medicaid, which provides health care for millions of low-income and disabled Americans. During an address to Congress last month, Trump said his administration had found “” without citing any specific examples of fraud.

“Taken back a lot of that money,” Trump said. “We got it just in time.”

But Trump’s history of showing leniency to convicted fraudsters contrasts with his present-day crackdown. In his first and second terms, Trump has granted pardons or commutations to at least 68 people convicted of fraud crimes or of interfering with fraud investigations, according to a ºÚÁϳԹÏÍø News review of court and , DOJ press releases, and news reports. At least 13 of those fraudsters were convicted in cases involving more than $1.6 billion in fraudulent claims filed with Medicare and Medicaid, according to the Department of Justice.

And as one of the first actions of his second term, Trump responsible for rooting out fraud and waste in government.

“It sends a really bad message and really hurts DOJ efforts at creating deterrence,” said Jacob Elberg, a former assistant U.S. attorney and law professor at Seton Hall University in New Jersey. “In order to reduce health care fraud, you need people both to be afraid of getting in trouble, but also for people to believe in the legitimacy of the system.”

Elberg said considerable fraud in Medicare and Medicaid exists largely because the programs’ “pay-and-chase models” prioritize paying for patient care first and tracking down stolen dollars second. To prevent more fraud, the programs would likely need to be redesigned in ways that would be slower and more cumbersome for all patients, Elberg said.

Regardless, Elberg said the president’s claimed focus on fraud appears to be a pretext for slashing spending that has been legally appropriated by Congress. Trump has empowered the Elon Musk-led Department of Government Efficiency, which he established and named by executive order, to make , halting some medical research and aid programs in addition to cutting spending on climate change, transgender health, and diversity, equity, and inclusion programs.

“What’s been the focal point to date of the administration is not what anybody has ever referred to as health care fraud,” Elberg said. “There is a real blurring — a seemingly intentional blurring — between what is actually fraud and what is just spending that they are not in favor of.”

Jerry Martin, who served as a U.S. attorney for the Middle District of Tennessee under President Barack Obama and now represents health care fraud whistleblowers, also said Trump’s focus on fraud appeared to be “just a platform to attack things that they don’t agree with” rather than “a genuine desire to root out and combat fraud.”

Even so, Martin said some of his whistleblower clients have been emboldened.

“I’ve had clients repeat back to me ‘President Trump says fraud is a priority,’” Martin said. “People are listening to it. But I don’t know that what he’s saying translates into what they believe.”

The White House did not respond to requests for comment for this article.

A Billion-Dollar Fraud Case and Needless Eye Injections

Presidents enjoy the unique authority to erase federal convictions and prison sentences with pardons and commutations. In theory, the power is intended to be a final bulwark against injustice or overly harsh punishment. But many presidents have been accused of using the pardon power to reward powerful allies and close associates as they leave the White House.

Trump issued about 190 pardons and commutations in the final two months of his first term, including for some health care fraudsters convicted of schemes with astonishing costs.

For example, Trump granted a commutation to Philip Esformes, a Florida health care executive convicted in 2019 of a $1.3 billion Medicare and Medicaid fraud scheme. After he was sentenced, DOJ announced in a press release that “the man behind one of the biggest health care frauds in history will be spending 20 years in prison.” Trump freed him 14 months later.

Trump also granted a commutation to Salomon Melgen, a Florida eye doctor who was serving a 17-year prison sentence for defrauding Medicare of $42 million. Melgen falsely diagnosed patients with eye diseases, then gave them unnecessary care, including laser treatments and painful eye injections, according to DOJ and court documents.

“Salomon Melgen callously took advantage of patients who came to him fearing blindness,” said after Melgen was sentenced in 2018. “They received medically unreasonable and unnecessary tests and procedures that victimized his patients and the American taxpayer.”

DOJ: $70 Million Spent on ‘Excessive’ Urine Testing

Despite the flurry of pardons and commutations at the end of Trump’s first term, the leniency he showed Davis was unique. Davis was the only convicted health care fraudster to receive clemency while the Trump administration was simultaneously accusing him of more fraud.

As CEO of Comprehensive Pain Specialists from 2011 to 2017, Davis oversaw a rapid expansion to more than 60 locations across 12 states, according to .

He was indicted in 2018 for using his CEO position to refer Medicare patients in need of medical equipment to a conspirator in return for kickbacks paid through a shell company, according to court documents. He was convicted at trial in April 2019 of defrauding Medicare.

Three months later, the DOJ filed a fraud lawsuit against Davis and CPS that piggybacked on the claims of seven whistleblowers. The lawsuit alleged that CPS collected more than $70 million from federal insurance programs for urine drug testing, most of which was “excessive,” and that an audit of a sampling of the tests had found at least 93% “lacked medical necessity.”

Typically, government insurance programs pay for urine testing so pain clinics can verify that patients are taking their prescriptions properly and not abusing any other drugs, which could contribute to an overdose. Patients could be tested as little as once a year or as often as monthly depending on their level of risk, according to the DOJ lawsuit.

But Comprehensive Pain Specialists performed “myriad urine drug testing on virtually every CPS patient on virtually every visit” then conducted “at least 16 different types of tests” on each sample, and sometimes as many as 51, according to the lawsuit.

Trump commuted Davis’ sentence for his criminal conviction in January 2021 as the DOJ was finalizing a settlement in the civil lawsuit. The commutation was supported by country music star Luke Bryan, according to a White House statement.

Months later, with President Joe Biden in office, CPS and its owners agreed to repay $4.1 million — less than 10% of the damages sought in the suit — and the case was closed.

In the settlement, Davis agreed not to take any job where he would ever again bill Medicare or other federal health care programs. He was not required to personally repay anything.

Martin, who represented one of the whistleblowers who first raised allegations against Davis and CPS, said the leniency that Trump showed to him and other health care fraudsters may discourage DOJ employees from pursuing similar investigations during his second term.

“There are a lot of rank-and-file people who are operating at the lowest point in their professional careers, where they’ve seen a lot of their work essentially be water under the bridge,” Martin said. “That’s got to be really demoralizing.”

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The spouse hadn’t responded to calls from other employees at the Rocky Mountain Lions Eye Bank, he said. As Lopez recalled, his supervisor thought a friend’s personal number would have more success.

Lopez refused. “I went for a walk,” he said.

Even without Lopez’s help, the eye bank that procures corneas from deceased donors in Wyoming and Colorado eventually collected his friend’s corneas, Lopez said. Lopez, who had entered the field to help people, became increasingly disillusioned during his three years working with the eye bank, despite rising from a technician to the distribution manager, and ultimately quit.

Checking the “donor” box on a driver’s license application, people may picture their heart, kidneys, or other organs saving another person’s life should the worst happen.

They are less likely to consider that tissues — corneas, tendons, bone marrow, skin, bone — are also covered by that checked box. In fact, donated tissues are collected much more frequently than organs, and corneas are the in the U.S., with , according to the Eye Bank Association of America.

Organ and tissue donations are guided by different rules, with less transparency and what critics identify as more self-policing in the tissue donation industry. In Wyoming and Colorado, where the Rocky Mountain Lions Eye Bank estimates it collects eye tissue from about , that has contributed to a tense work environment resulting in damaged or wasted tissues due to accidents, four former eye bank employees say.

“I think there’s an urgent need for stricter oversight of the donation process in general, particularly for eye and tissue banks,” said Janell Lewis, who worked at the Rocky Mountain Lions Eye Bank for 12 years, managing public relations and overseeing fundraising before she quit in February 2023.

John Lohmeier, executive director of the Rocky Mountain Lions Eye Bank, declined to be interviewed for this article. In a prepared statement, he said he couldn’t comment on personnel matters or specific incidents raised by the former employees.

But generally, he wrote, “there are internal procedures that have been in place and continue to be followed to investigate and/or report any incident that would impact health and safety concerns.”

Lewis, Lopez, and two other former eye bank employees recalled one or more of the following problems during their time at Rocky Mountain Lions Eye Bank:

• Removal of eye tissue from the wrong body
• Damage or destruction of corneas due to improper removal
• Removal of corneas from a donor with a high-risk family history that could endanger a transplant recipient
• Lack of transparency about whether errors were being reported to federal agencies
• Pressuring and bullying of technicians
• High turnover and brief training of low-paid and inexperienced technicians

The Windshield of the Eye

The cornea is considered the . It is a clear dome that protects the eye from contaminants, maintains fluid balance, and filters light. Recipients of cornea donations typically need transplants because of trauma, infection, or that cause blindness or blurred or cloudy vision.

The Rocky Mountain Lions Eye Bank is one of about 60 eye banks operating in the U.S., in corneal transplants. New technicians often arrive at the eye bank untrained, sometimes with only a high school diploma, to perform the grim job of removing corneas from recently deceased corpses for about the same wages many fast-food workers earn.

But what eye bank technicians may lack in education and training, they generally make up for with a strong belief in the mission, according to the former employees. They said they joined the Rocky Mountain Lions Eye Bank because they wanted to help restore people’s sight.

The nonprofit employs about 70 people across Colorado and Wyoming, according to a submitted in 2023. Those records also show a net income of less than $1 million and more than $16 million in assets. Lohmeier was paid about $142,000.

Organs vs. Tissue

Organ donations fall under the purview of the Health Resources and Services Administration, and details performance and of organ procurement groups. Tissue donation is regulated by the Food and Drug Administration, as well as national industry groups, and tissue bank transactions, performance, and outcomes are not available to the public.

There’s no reason tissues and organs should be treated differently, said Robert Dickson, medical director for the Washtenaw County Tuberculosis Clinic in Michigan. A patient in his county died from a bone graft contaminated with tuberculosis just a couple of years after a contaminated bone graft .

He to the Wild West and called it a major public health concern.

“It’s fundamentally no different from an organ transplant. You’re taking tissue from one deceased patient and putting it into a living recipient. But it is not regulated and not tested as rigorously,” he said.

Marc Pearce, president and CEO of the American Association of Tissue Banks, said such cases are very rare.

“We don’t believe that we’ve proven ourselves to be not capable of regulating ourselves,” he said.

FDA officials disagree that the tissue industry is largely self-regulated, pointing to that require certain organizations to register with the agency and provide a list of human cells or tissues they recover, store, or distribute.

The rules set donor eligibility requirements, and the agency inspects tissue establishments, including eye banks, said spokesperson Carly Pflaum.

“The FDA has implemented a tiered risk-based approach for the regulation of human cell, tissue and cellular and tissue-based products,” Pflaum wrote.

ºÚÁϳԹÏÍø News and WyoFile months ago requested reports of adverse events associated with the Rocky Mountain Lions Eye Bank, but the FDA has yet to provide them. FDA dashboards show the eye bank since 2017, and inspections since at least 2009 in any official action.

The tissue industry is largely self-monitored and the performance of eye banks is tracked internally, whereas the federal government publishes for organ procurement groups. Health care providers are not required to report to the FDA adverse events resulting from tissue transplants.

Organ transplant providers are required to report safety events in recipients within 72 hours to the Organ Procurement and Transplantation Network, which operates under contract with the U.S. Department of Health and Human Services. That includes an organ going unused because it was delivered to the wrong location. They have 24 hours if, for example, the recipient gets an infection or disease that may have been from the new organ.

Other countries have public registries detailing the outcomes of corneal transplants, including Australia, the United Kingdom, and Sweden. A similar registry in the U.S. could help monitor outcomes for patients and identify adverse events from transplant procedures, eye doctors and researchers wrote in .

Tissue bank industry groups are responsible for much of the oversight of their dues-paying members. Transplanting surgeons may report adverse reactions to the tissue bank, which generally then conducts a review and submits a report to the FDA and the Eye Bank Association of America or the American Association of Tissue Banks.

Nearly all eye banks in the U.S. are members of the Eye Bank Association of America, which inspects member banks at least every three years as part of its accreditation process, but such inspection reports aren’t publicly available. Safety is paramount, association president Kevin Corcoran said, and the association’s medical standards require eye banks to request patient outcome information from transplanting surgeons a few months after surgery.

“We want to make sure we don’t have an eye bank that is slipping in their performance or failing to recover tissue,” he said. He declined to comment on any individual eye bank’s performance or release quality or transplantation data, complaints filed, or investigations undertaken.

No investigations have resulted in corrective action, he said, in the 13 years he has been at the association. The Rocky Mountain Lions Eye Bank is an accredited member of the association.

Balancing Mission and Stress

Several of the former employees were hesitant to speak about the Rocky Mountain Lions Eye Bank because they didn’t want to sully the reputation of an industry they believe is essential for improving people’s lives and honoring the wishes of the dead.

But they described a high-pressure environment that they said led to many of their colleagues leaving and errors that reduced the number of successful retrievals.

Mackenzie Urban started recovering corneas as a technician for the eye bank in 2019 after finishing her bachelor’s degree. She saw it as a temporary job as she applied for medical school. But within a year of recovering her first cornea, she said, enough employees had left that she became the senior recovery technician and was training others.

She used limes for the training, guiding her students on how to use a scalpel to remove the peel without nicking the fruit beneath. Success meant lifting the peel off the lime without any juice spilling out.

“If you’re stressed, you’re going to shake,” Urban said.

Outside factors can compound the challenges of performing the delicate procedure. Maybe the coroner had drawn fluid from beneath the cornea, making collection much trickier, she said. After a person has been dead for about 24 hours, the eyes tend to deflate to the point of uselessness, adding time pressure to collecting donations, Urban said.

Sometimes, Urban said, another technician would be working on a body simultaneously, so that the entire body was moving around while she was trying to do the delicate procedure.

Interactions with grieving families could be intense, too. Sometimes, families would hug her, thankful that something good would come of their loss. Other times, they were hostile, such as the time one relative of a potential donor told her to “Cut your own f* eyes out, you b****,” she recalled.

Urban appreciates the work the eye bank performs and doesn’t regret her time there. She said she respected that “they had a real commitment to serving the community and keeping prices low.” (It’s illegal to sell human body parts for transplant, but companies get reimbursed varying amounts for the expenses of harvesting, preparing, and shipping tissues.)

But the workplace culture made it untenable for her, she said. For example, Urban said, she was reprimanded and told that she needed to “buck up or get out” because she declined to harvest corneas from a person who died from an unknown cause. The body was purple from the neck down, covered in oozing blisters and with opaque flecks in the eyes, Urban said.

When Irish Eyes Are Smiling

The Rocky Mountain Lions Eye Bank has international contracts and ships corneas to Japan and the U.K., among other destinations. It became the exclusive eye tissue provider for Ireland when that country stopped collecting corneas over fears of transmitting mad cow disease. That means anyone who has received in the past two decades likely now sees thanks to a person who died in Colorado or Wyoming, according to the Irish Blood Transfusion Service.

Lohmeier, the eye bank CEO, said local needs are prioritized for donations, while international shipments help fulfill the eye bank’s mission and “ensure that all viable corneas are transplanted, giving the gift of restored sight.”

The U.S. is one of the few nations with a . FDA inspection reports confirmed that the Rocky Mountain Lions Eye Bank procures more tissue than its geographic area can use.

The demand for international orders contributed to the high-pressure environment, Lopez said.

Employee turnover and the stress of the job resulted in the collection of corneas of poor quality, Lewis said. Local hospitals inquired about why so many corneas weren’t being transplanted, she added.

The leading reason was recovery errors that damaged the tissue, Lewis said.

Lohmeier disagreed that there was a significant decline in corneas being placed. “We do not believe this description accurately reflects the state of corneal recovery and transplants,” he said.

Internal records showed that about half of recovered corneas in November 2022 had moderate to heavy stress. The Eye Bank Association of America does not have comparable national data. The closest figure it tracks is the proportion, among tissues that were prepared but not transplanted, that were unable to be transplanted because of damage during processing; in 2022, it was a quarter.

Ashi Moore, who used to lead the Rocky Mountain Lions Eye Bank’s quality assurance department, said she once filed a report to the FDA after a donor’s eye tissues were removed despite a family history indicating a high risk of Creutzfeldt-Jakob disease. The disease, which should have been disqualifying for donation purposes, is a fatal brain disorder that through infected tissue.

The issue was caught before the corneas could be placed in someone else’s eyes, but it should never have gotten to the point that the corneas were removed from the body, Moore said.

At least once, a technician retrieved corneas from the wrong body, according to Moore and other former employees. (The FDA was unable to provide records to confirm that report by publication.) Moore said she should have been told about the case of mistaken identity immediately but said she wasn’t made aware of it until after the eye bank’s leaders handled the situation themselves.

She said she couldn’t find evidence that the eye bank had reported the error to the FDA. It was one of the major reasons she decided to leave the organization, though she had derived a strong sense of purpose from working at the eye bank, she said.

When Lewis resigned, officials at the nonprofit eye bank offered her $5,000 to sign a severance agreement with a nondisparagement provision. She declined.

Lewis said she would like to see states hold tissue recovery agencies to the same standards as other organizations that handle corpses, such as hospitals, coroners, and funeral homes. And if they fail to meet those standards, they need to be held accountable to build public trust, she said.

Lewis’ and Lopez’s negative experiences with the eye bank had another consequence. Each decided they no longer wanted to be an organ or tissue donor.

“After witnessing and experiencing so many issues, I no longer feel comfortable with the potential of my family having to go through that when the time comes,” Lewis said.

WyoFile is an independent nonprofit news organization focused on Wyoming people, places, and policy.

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His clinics, Tarzana Treatment Centers, are among the early adopters of an AI-based system that promises to dramatically expand screening for diabetic retinopathy, the leading cause of blindness among working-age adults and a threat to many of the estimated 38 million Americans with diabetes.

“It’s been a godsend for us,” said Espinoza, the organization’s director of clinic operations, citing the benefits of a quick and easy screening that can be administered with little training and delivers immediate results.

His patients like it, too. Joseph Smith, who has Type 2 diabetes, recalled the cumbersome task of taking the bus to an eye specialist, getting his eyes dilated, and then waiting a week for results. “It was horrible,” he said. “Now, it takes minutes.”

Amid all the buzz around artificial intelligence in health care, the eye-exam technology is emerging as one of the first proven use cases of AI-based diagnostics in a clinical setting. While the FDA has approved hundreds of , adoption has been slow as vendors navigate the regulatory process, insurance coverage, technical obstacles, equity concerns, and challenges of integrating them into provider systems.

The eye exams show that the AI’s ability to provide immediate results, as well as the cost savings and convenience of not needing to make an extra appointment, can have big benefits for both patients and providers. Of about 700 eye exams conducted during the past year at Espinoza’s clinics, nearly one-quarter detected retinopathy, and patients were referred to a specialist for further care.

Diabetic retinopathy results when high blood sugar harms blood vessels in the retina. While managing a patient’s diabetes can often prevent the disease — and there are treatments for more advanced stages — doctors say regular screenings are crucial for catching symptoms early. An  in the U.S. have the disease.

The three companies with FDA-approved AI eye exams for diabetic retinopathy — Digital Diagnostics, based in Coralville, Iowa; Eyenuk of Woodland Hills, California; and Israeli software company AEYE Health — have sold systems to hundreds of practices nationwide. A few dozen companies have conducted research in the narrow field, and some have regulatory clearance in other countries, including .

, formerly Idx, received FDA approval for its system in 2018, following decades of research and a clinical trial involving 900 patients diagnosed with diabetes. It was the first fully autonomous AI system in any field of medicine, making its in medical history,” said Aaron Lee, a retina specialist and an associate professor at the University of Washington.

The system, used by Tarzana Treatment Centers, can be operated by someone with a high school degree and a few hours of training, and it takes just a few minutes to produce a diagnosis, without any eye dilation most of the time, said John Bertrand, CEO of Digital Diagnostics.

The setup can be placed in any dimly lit room, and patients place their face on the chin and forehead rests and stare into the camera while a technician takes images of each eye.

The American Diabetes Association recommends that people with Type 2 diabetes get screened every one to two years, yet only about 60% of people living with diabetes get yearly eye exams, said Robert Gabbay, the ADA’s chief scientific and medical officer. The rates can be for people with diabetes age 21 or younger.

In swaths of the U.S., a and ophthalmologists can make appointments hard to schedule, sometimes booking for months out. Plus, the barriers of traveling to an additional appointment to get their eyes dilated — which means time off work or school and securing transportation — can be particularly tricky for low-income patients, who also have a .

“Ninety percent of our patients are blue-collar,” said Espinoza of his Southern California clinics, which largely serve minority populations. “They don’t eat if they don’t work.”

One potential downside of not having a doctor do the screening is that the algorithm solely looks for diabetic retinopathy, so it could miss other concerning diseases, like choroidal melanoma, Lee said. The algorithms also generally “err on the side of caution” and over-refer patients.

But the technology has shown another big benefit: Follow-up after a positive result is three times as likely with the AI system, according to a by Stanford University.

That’s because of the “proximity of the message,” said David Myung, an associate professor of ophthalmology at the Byers Eye Institute at Stanford. When it’s delivered immediately, rather than weeks or even months later, it’s much more likely to be heard by the patient and acted upon.

Myung launched Stanford’s in 2020, originally focusing on telemedicine and then shifting to AI in its Bay Area clinics. That same year, the National Committee for Quality Assurance expanded its screening standard for diabetic retinopathy to include the AI systems.

Myung said it took about a year to sift through the Stanford health system’s cybersecurity and IT systems to integrate the new technology. There was also a learning curve, especially for taking quality photos that the AI can decipher, Myung said.

“Even with hitting our stride, there’s always something to improve,” he added.

The AI test has been bolstered by a reimbursement code from the Centers for Medicare & Medicaid Services, which can be difficult and time-consuming to obtain for breakthrough devices. But health care providers need that government approval to get reimbursement.

In 2021, CMS set the national payment rate for AI diabetic retinopathy screenings at $45.36 — quite a bit below the median privately negotiated rate of $127.81, according to a . Each company has a slightly different business model, but they generally charge providers subscription or licensing fees for their software.

The companies declined to share what they charge for their software. The cameras can and are either purchased separately or wrapped into the software subscription as a rental.

The greater compliance with screening recommendations that the machines make possible, along with a corresponding increase in referrals to specialists, makes it worthwhile, said Lindsie Buchholz, clinical informatics lead at Nebraska Medicine, which in mid-December began using Eyenuk’s system.

“It kind of helps the camera pay for itself,” she said.

Today, Digital Diagnostics’ system is in roughly 600 sites nationwide, according to the company. AEYE Health said its eye exam is used by “low hundreds” of U.S. providers. Eyenuk declined to share specifics about its reach.

The technology continues to advance, with clinical studies for additional cameras — including that can screen patients in the field — and looking at other eye diseases, . The innovations put ophthalmology alongside radiology, cardiology, and dermatology as specialties in which AI innovation is happening fast.

“They are going to come out in the near future — cameras that you can use in street medicine — and it’s going to help a lot of people,” said Espinoza.

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The office was already closed, but the whole eye care team was there waiting for me. One of them pricked my eyeballs with a sharp instrument, allowing the ocular fluid that had built up to drain. That relieved the pressure and restored my vision.

But it was the fourth vision-impairing pressure spike in nine days, and they feared it would happen again — heading into a weekend. So off I went to the emergency room, where I spent the night hooked up to an intravenous tube that delivered a powerful anti-swelling agent.

Later, when I told this story to friends and colleagues, some of them didn’t understand the importance of eye pressure, or even what it was. “I didn’t know they could measure blood pressure in your eyes,” one of them told me.

Most people consider their vision to be vitally important, yet many lack an understanding of some of the most serious eye diseases. A published in JAMA Ophthalmology, based on an online national poll, showed that nearly half of respondents feared losing their eyesight more than their memory, speech, hearing, or limbs. Yet many “were unaware of important eye diseases,” it found.

A study released in July, conducted by Wakefield Research for the nonprofit and , showed that one-quarter of adults deemed at risk for diseases of the retina, such as macular degeneration and diabetic retinopathy, had delayed seeking care for vision problems.

“There is significantly less of an emphasis placed on eye health than there is on general health,” says Rohit Varma, founding director of the at Hollywood Presbyterian Medical Center.

Because eye diseases can be painless and progress slowly, Varma says, “people get used to it, and as they age, they begin to feel, ‘Oh, this is a normal part of aging and it’s OK.’” If people felt severe pain, he says, they would go get care.

For many people, though, it’s not easy to get an eye exam or eye treatment. Millions are uninsured, others can’t afford their share of the cost, and many live in communities where eye doctors are scarce.

“Just because people know they need the care doesn’t necessarily mean they can afford it or that they have the access to it,” says Jeff Todd, CEO and president of Prevent Blindness.

Another challenge, reflecting the divide between eye care and general health care, is that medical insurance, except for children, often covers only eye care aimed at diagnosing or treating diseases. More health plans are covering routine eye exams these days, but that generally does not include the type of test used to determine eyeglass and contact lens prescriptions — or the cost of the lenses. You may need separate vision insurance for that. Ask your health plan what’s covered.

Since being diagnosed with glaucoma 15 years ago, I’ve had more pressure checks, eye exams, eyedrops, and laser surgeries than I can remember. I should know not to take my eyesight for granted. And yet, when my peepers were filling with that vision-threatening fog last March, I felt oddly sanguine.

It turned out that those serial pressure spikes were triggered by an adverse reaction to steroid-based eyedrops prescribed to me following cataract surgery. My ophthalmologist told me later that I had come “within hours” of losing my eyesight.

I hope my brush with blindness can help inspire people to be more conscious of their eyes.

Eyeglasses or contact lenses can make a huge difference in one’s quality of life by correcting , which affect 150 million Americans. But don’t ignore the risk of far more serious eye conditions that can sneak up on you. They are often manageable if caught early enough.

Glaucoma, which affects in the U.S., attacks peripheral vision first and can cause irreversible damage to the optic nerve. It runs in families and is among African Americans as in the general population.

in this country have diabetic retinopathy, a complication of diabetes in which blood vessels in the retina are damaged. And some age 40 and up have macular degeneration, a disease of the retina associated with aging that diminishes central vision over time.

The formation of cataracts, which cause cloudiness in the eye’s natural lens, is very common as people age: have them. Cataracts can cause blindness, but they are eminently treatable with surgery.

If you are over 40 and haven’t had a comprehensive eye exam in a while, or ever, put that on your to-do list. And get an exam at a younger age if you have diabetes, a family history of glaucoma, or if you are African American or part of another racial or ethnic for certain eye diseases.

And don’t forget children. can affect kids. Refractive errors, treatable with corrective lenses, can cause impairment later in life if they are not addressed early enough.

Healthful lifestyle choices also benefit your eyes. “Anything that helps your general health helps your vision,” says Andrew Iwach, a clinical spokesperson for the and executive director of the .

Minimize stress, get regular exercise, and eat a healthy diet. Also, quit smoking. It of major eye diseases.

And consider adopting habits that protect your eyes from injury: Wear sunglasses when you go outside, take regular breaks from your computer screen and cellphone, and wear goggles when working around the house or playing sports.

The offers information on virtually everything related to eye health, . Other good sources include the American Academy of Ophthalmology’s and the .

So read up and share what you’ve learned.

“When you get together for the holidays,” says Iwach, “if you aren’t sure what to talk about, talk about your eyes.”

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When Jerry Bilinski, a 67-year-old retired social worker, scheduled cataract surgery with Carolina Eye Associates near his home in Fayetteville, North Carolina, he expected no drama, just a future with better vision.

Cataract procedures are among the most common surgeries in the U.S. — take place annually — and generally take about 30 minutes under light sedation. At the same time, the surgeon scheduled the placement of a little stent inside Bilinski’s eye to relieve pressure from his diabetes-related glaucoma, also a routine procedure to preserve his eyesight.

Bilinski recalled being sedated during the surgery in May and hearing a nurse anesthetist ask him whether he felt any pain. Bilinski said no — only some pressure on the right side of his head. He said the nurse anesthetist responded that he would increase the sedation. Despite being under anesthesia, Bilinski knew something was wrong.

“The next thing I know there’s some sort of commotion going on, and I hear the doctor yelling at me, ‘Don’t move! Stay still!’ — yelling in my ear,” Bilinski said. “And then I hear the doctor say, ‘What’s that cut on his head?’”

It was a small abrasion — nothing serious, he said — but it went unmentioned by the staff. At home, he took a nap and awoke to blood on his pillow. Memories of the incident came flooding back.

His doctor mentioned nothing about the incident at his post-operative appointment, so Bilinski brought it up. “I said, ‘You know, doctor, I just have some questions for you because I have some memories of some things happening there,’” he said. “And at that point, I think she probably knew the jig was up and said, ‘Yeah, we had a little incident. You had a little adverse impact from the anesthesia.’”

The surgery was a success, and the cut on his forehead healed. But Bilinski wanted to know more about his reaction to the sedation. Later, when he got his medical records, they said the surgery had “no complications.”

“They hid it,” Bilinski said.

Then the bill came.

The Patient: Jerry Bilinski, 67, a retiree who has traditional Medicare and a supplemental Medicare plan through UnitedHealthcare.

Medical Service: Cataract removal and replacement of a lens, plus insertion of a Hydrus Microstent device to treat glaucoma.

Service Provider: Bilinski’s procedure was performed at the by Dr. Tarra Millender of Carolina Eye Associates, a chain of medical and surgical eye care centers headquartered in Southern Pines, North Carolina.

Total Bill: $1,805 for the doctor’s fee for cataract surgery and insertion of a stent. Bilinski’s portion of that bill was $54. In addition, Fayetteville Ambulatory charged Medicare $10,745 for the surgery. Medicare paid $2,377 to the surgery center, and Bilinski’s supplemental Medicare plan paid an additional $550. Bilinski owed $50 to the surgery center.

What Gives: Professional standards of care dictate that medical providers inform patients about injuries that happen during surgery. But what should happen next — whether that’s an apology or an offer to waive some portion of the bill — is an open question in the U.S. health care system. Another question: If the injury requires treatment — if, for example, Bilinski’s cut had needed stitches (it didn’t) — who should foot the bill?

T.J. McCaskill, chief operating officer for Carolina Eye Associates, declined an interview request, citing federal and state patient privacy laws, even though Bilinski gave permission for the details of his medical case to be released to a reporter. Millender, the doctor, did not return a reporter’s messages.

When patients experience adverse reactions during treatment, they are generally expected to pay the cost of bringing themselves back to good health. That might make sense if the reaction — such as an allergic reaction to a new antibiotic — could not have been anticipated. But what if the injuries are the result of negligence, carelessness, or a medical mishap (after all, providers are human and accidents happen)?

After reviewing details about Bilinski’s case, Arthur Caplan, a professor of bioethics at New York University’s Grossman School of Medicine in New York City, said he found the injury bizarre. He said he couldn’t understand why an adverse reaction to anesthesia would lead to a bloody forehead.

“That gash is pretty weird,” Caplan said. “If someone asked me to pay a bill on this, I would have said ‘no’ until we get this resolved.”

Caplan said a case like Bilinski’s would be unlikely to pose a legal risk for the provider; most attorneys will not accept a case in which any damage awards are likely to be small.

In some cases, doctors and medical offices do voluntarily give rebates to patients injured during treatment, Caplan said. A patient who experienced an infection at the site of an IV, for example, and needed a few extra days in the hospital for antibiotics might not be billed for the extra days.

“There is no standard policy,” he said. “That’s the doctor’s or medical practice’s decision.”

Resolution: The cut on his forehead healed, but Bilinski — who spent his career working in health care — felt he deserved to know what had caused the injury.

“If you make medical records that are not accurate, it puts people in danger,” he said. “In my case, it indicates that I had a certain anesthesia at a certain dosage, which in fact produced an adverse and potentially dangerous side effect, and that’s not in there. And instead it says everything went well and that I tolerated the procedure well.”

Bilinski said he talked with McCaskill, the executive from Carolina Eye Associates, but did not receive an apology or a satisfactory explanation.

Medicare, a government insurance program that typically serves seniors and people with disabilities, and a secondary insurance plan Bilinski carries through UnitedHealthcare covered most of the costs of the Medicare-negotiated rates for the surgery.

Bilinski owed his modest, predictable Medicare copays, as most enrollees do after surgical procedures. But Bilinski said he believes taxpayers were cheated because the handling of his injury was unprofessional and Medicare paid its full fee for a procedure during which something went awry.

He filed a complaint with the North Carolina Medical Board, which licenses physicians and investigates allegations of medical mistakes and wrongdoing. He also filed an affidavit with the Fayetteville Police Department. (A police representative told Bilinski it was a civil matter, not criminal, so not in the police department’s purview.)

A medical board spokesperson, Jean Fisher Brinkley, declined an interview request, saying the agency doesn’t publicly discuss ongoing investigations.

“How many other people has this kind of thing happened to?” Bilinski said.

The Takeaway: If you have questions about something unexpected that occurs during medical treatment, request a copy of your full record. In Bilinski’s case, his record said there were “no complications” with the procedure. That clearly was not quite true, Bilinski said.

Patients injured during a procedure can ask for a rebate or seek to have insurance copays waived, Caplan said. They can also file a complaint with a state medical board to try to find out what happened and whether professional standards were violated.

Medical care is often unpredictable, but if an avoidable injury happens, the patient should not necessarily have to pay for that to be remedied, Caplan said.

Patients are frequently left holding the bag for extended hospital stays and reparative treatments for events that are not their fault. They might have to stay in the hospital three extra nights, over a weekend, for example, because a social worker wasn’t available for discharge planning on Friday. If a defective joint implant is put into a knee, the costs of replacing it are often borne by the patient and the insurer. (Although a lawsuit might eventually lead to a full or partial reimbursement from the manufacturer, such cases typically take years to get to a judgment.)

Patients should fight back and refuse to pay such bills, Caplan advised. Likewise, doctors in such situations should be fully transparent about what occurred and why. Though some physicians may worry about the risk of a malpractice suit, studies have shown that , often extinguishes a patient’s ire. Such apologies are required by professional ethics, and in some states they are required by law, as well.

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But the former English professor said her 2019 surgery with Ophthalmology Consultants didn’t get her to 20/20 vision or fix her astigmatism — despite a $3,000 out-of-pocket charge for the astigmatism surgical upgrade. Green, 69, said she ended up feeling more like a dollar sign to the practice than a patient.

“You’re a cow among a herd as you just move from this station to this station to this station,” she said.

Ophthalmology Consultants is part of EyeCare Partners, one of the largest private equity-backed U.S. eye care groups. It is headquartered in St. Louis and counts some in its networks across 19 states. The group declined to comment.

Switzerland-based Partners Group bought EyeCare Partners in 2019 for . Another eye care giant, Texas-based , was formed in 2020 from Massachusetts-based Webster Equity Partners, a private equity firm, and now it it has 190 physicians across 18 states. Other private equity groups are building regional footprints with practices such as and . Acquisitions have escalated so much that private equity firms now are routinely selling practices to one another.

In the past decade, private equity groups have gone from taking over a handful of practices to working with as many as 8% of the nation’s ophthalmologists, said Dr. Robert E. Wiggins Jr., president of the .

They are scooping up eye care physician practices nationwide as money-making opportunities grow in medical eye care with the aging of the U.S. population. Private equity groups, backed by wealthy investors, buy up these practices — or unify them under franchise-like agreements — with the hopes of raising profit margins by cutting administrative costs or changing business strategies. They often then resell the practices at a higher price to the next bidder.

The profit potential for private equity investors is clear: Much like paying to upgrade plane seats to first class, patients can choose expensive add-ons for many eye procedures, such as cataract surgery. For example, doctors can use lasers instead of cutting eye lenses manually, offer multifocal eye lenses that can eliminate the need for glasses, or recommend the astigmatism fix that Green said she was sold. Often, patients pay out-of-pocket for those extras — a health care payday unconstrained by insurance reimbursement negotiations. And such services can take place in outpatient and stand-alone surgery centers, both of which can be more profitable than in a hospital setting.

The investments that private equity groups provide can help doctors market and expand their practices, as well as negotiate better prices for drugs and supplies, Wiggins said. But he warned that private equity companies’ quest to maximize profitability runs the risk of compromising patient care.

“The problems are accumulating and driving up prices,” added Aditi Sen, director of research and policy at the nonprofit , which provides data and analysis about the economics of health care.

, a health economist at Johns Hopkins University, and her colleagues analyzed private equity acquisitions in ophthalmology, gastroenterology, and dermatology and found that practices charged insurance an extra 20%, or an average of $71, more after the acquisition. Private equity-owned practices also saw a substantial rise in new patients and more frequent returns by old patients, according to their research, .

A KHN analysis also found that private equity firms are investing in the offices of doctors who prescribe at high rates two of the most common macular degeneration eye drugs, meaning the doctors are likely seeing high volumes of patients and thus are more profitable.

KHN analyzed the top 30 prescribers of the macular degeneration eye drugs Avastin and Lucentis in 2019 through a . Private equity companies went on to invest in 23% of the top Avastin prescribers, and 43% of the top Lucentis prescribers — far higher than the 8% of ophthalmologists in which private equity currently holds a stake. Retina Consultants of America, for example, has invested in the practices of four of the top Avastin prescribers, and nine of the top Lucentis prescribers.

“The private equity model is a model that focuses on profitability, and we know they are not selecting practices randomly,” Sen said.

She noted that the volume of patients would be attractive to private equity, as well as the idea of investing in practices utilizing expensive Lucentis prescriptions, which cost roughly $1,300 an injection. Furthermore, she said, after being acquired by private equity, doctors could potentially change their prescription habits from the cheaper Avastin that costs about $40 to Lucentis – improving the bottom line.

Retina Consultants of America did not respond to requests for comment.

Last summer, Craig Johnson, then 74, decided it was finally time to have cataract surgery to fix his deteriorating eyes. He decided to go to CVP Physicians in Cincinnati, calling it “the cream of the crop locally for having eye surgery” as they do “100 a day.” The practice was already part of a private equity investment but has since been acquired by another investor, behemoth EyeCare Partners, .

Johnson, while happy with the results of his surgery, did not know about the manual cutting version of the surgery — the cheaper but just as effective alternative to using a laser. Johnson was using private insurance because he was still working, and he said that resulted in over $2,000 out-of-pocket charges for each eye. Laser surgery typically costs more than manual and , according to the American Academy of Ophthalmology.

Johnson explained that a salesperson, as well as a physician, walked him through options to improve his eyesight.

“Seniors are a vulnerable population because they’re on a fixed income, they’re a little older, they trust you … you’re wearing a white coat,” said Dr. Arvind Saini, an ophthalmologist who runs in California’s San Diego County.

Many patients have no idea whether private equity investors have a stake in the practices they choose because they are often referred to them by another doctor or are having an eye emergency.

David Zielenziger, 70, felt lucky to get a quick appointment at one of Vitreoretinal Consultants of NY’s practices after his retina detached. Zielenziger, a former business journalist, didn’t know it was associated with Retina Consultants of America. He loved his doctor and had no complaints about the emergency care he received — and continued to go there for follow-ups. Medicare covered just about everything, he said.

“It’s a very busy practice,” he said, noting that it has expanded to more locations, which must be making the investors happy.

In 2018, Michael Kroin co-founded , a group that helps doctors sell their practices to private equity firms, to capitalize on the explosion of interest. Eye care is one of the largest areas of investment, he said, because the specialty health care services apply to such a broad market of people.

Sixteen of the 25 private equity firms identified by industry tracker PitchBook as the biggest health care investors have bought stakes in optometry and ophthalmology practices, a KHN analysis found.

Kroin expects private equity investment in practices will only continue to accelerate because of competition from the “1,000-pound gorilla” of hospitals that also are acquiring practices and as the bureaucracy of insurance reimbursement forces more physicians to seek outside help. “If you’re not growing, it’s going to be tough to survive and make a similar level of income as you had historically,” he said.

Some health care experts worry that private equity companies could eventually be left holding an overly leveraged bag if other firms don’t want to buy the practices they’ve invested in, which could lead to the closures of those practices and ultimately even more consolidation.

“I’m not sure that most physician practices are so inefficient that you can get 20% more profit out of them,” said Dr. , chief of the division of health policy and economics at Weill Cornell Medicine’s Department of Population Health Sciences. And, he said, investors count on reselling to a buyer who will pay more than what they paid. “If that doesn’t work, the whole thing unravels.”

KHN investigative reporter Fred Schulte contributed to this article.

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But the partnership that began more than 30 years ago has fractured. Medi-Cal enrollees, many of whom are children, and their eye care providers say that they often wait months for the glasses and that sometimes they arrive broken.

“I understand the aim of trying to give prisoners a worthy occupation,” said , senior managing director of health and research for a California-based child advocacy group, Children Now. “But not at the expense of kids being able to see.”

Medi-Cal’s contract with the , or CALPIA, a business enterprise within the California Department of Corrections and Rehabilitation that employs inmates, has been in place since 1988. Other Medicaid programs — including those in Massachusetts and North Carolina — rely on prison labor to fulfill the promises of their vision benefit.

Experts noted, though, that such innovations work only if patients receive their glasses in a timely manner. Complaints from consumers and eye professionals have led California lawmakers to consider an expensive proposal that would allow Medi-Cal to purchase glasses from retail labs.

San Francisco resident Jane Angel said her 6-year-old son, David Morando, waited two months for his glasses to be delivered. He needed them because “he sits in the back of his classroom,” Angel said. She’s concerned because David is also on the autism spectrum, so not being able to see is another reason that concentrating in class is hard for him. “He’s not able to see the board, and it’s just hard for him to learn,” Angel said.

Optometrists, too, have been frustrated by slow turnaround times and frequent prescription mistakes.

“There’s nothing that we can do to get the glasses quicker,” said Joy Grey, the office manager of Alpert Eye Care in Mission Viejo. Her clinic tracks pending glasses orders by keeping empty trays for each on a shelf. A few months ago, so many CALPIA orders were pending that Grey and her colleagues were running out of space for others. “That’s how backlogged we are,” she said.

A — including 40% of the state’s children, nearly 5.2 million kids — are enrolled in Medi-Cal. The federal government requires that Medicaid offer vision benefits for children. Medi-Cal has generally covered routine eye exams and a pair of glasses once every two years for this age group. In January 2020, California’s program expanded benefits to adults.

Orders for glasses from Medi-Cal to CALPIA rose from nearly 490,000 in 2019 to 654,000 in 2020 and then to 880,400 in 2021.

Medi-Cal pays CALPIA about $19.60 for every pair of glasses made, said Katharine Weir-Ebster, a spokesperson for the .

In an of 171 of its members in March, the California Optometric Association found that 65% of respondents had experienced waits of one to three months for glasses ordered for Medi-Cal patients. In comparison, the survey found that the average turnaround time for glasses from private labs was less than 15 days.

But CALPIA spokesperson Michele Kane said production has been moving much faster than that. She said orders from 2011 to 2020 were filled, on average, five days after labs received them, but turnaround times began to slip during the covid-19 pandemic and hit a peak in January 2021 with a 37-day average. Since then, she added, the wait times for orders have improved and reached nine days by April 2021 and are expected to get back to five days this month.

To speed up fulfillment of Medi-Cal glasses orders, Kane said, CALPIA contracts with nine “backup” labs. Five are in states outside California. Of the 880,400 orders CALPIA received last year, 54% were sent to the contracted private labs, Kane said. These labs send the glasses to CALPIA, which then mails them to the clinics that ordered them.

Kane blamed prison lockdowns and restrictions triggered by the covid pandemic for exacerbating what she said were previously system hiccups that could upend production in prison optical labs.

In the survey, however, more than half of the optometrists said they had not seen turnaround times improve significantly.

A by the California legislature seeks to address the issue by stripping away the exclusivity of the arrangement and allowing clinics to also order glasses from retail labs.

The measure is a “response to the shocking disparity in the level of optical care that the state provides to some of its most vulnerable residents,” (R-Santa Clarita), the bill’s sponsor, said in a written statement.

But it has a big price tag. An analysis by California’s Department of Health Care Services, which was referenced by lawmakers supporting the bill, estimates that the cost to Medi-Cal for a pair of glasses from private labs would be than what it pays CALPIA.

CALPIA employs 295 incarcerated people for optical programs in three prisons: Valley State Prison in Chowchilla; the California State Prison Solano in Vacaville; and, most recently, the Central California Women’s Facility in Chowchilla. When the optometric program at the women’s facility is in full operation, expected this month, that total will be 420.

One benefit of the partnership is that inmates learn skills they can use to get jobs after they complete their sentences. It also works to lower recidivism rates, Kane said.

Anthony Martinez, 40, knows the pros and cons of the system. He was incarcerated in 2000 at age 19. For the last three years of his decadelong sentence, he worked in the prison’s optical program. “That was an opportunity that I was going to take full advantage of,” Martinez said.

The day after his release, Martinez got a license from the American Board of Opticianry to manufacture and sell glasses. A month later, he was hired as a lab technician at a LensCrafters in Los Angeles and was eventually promoted to lab manager. By 2020, he had helped open three other eyeglasses stores across the state.

Martinez is aware of the benefits he gained from his experience in CALPIA’s optical program but understands the impact that long wait times have on patients, especially kids.

“I would think that it needs to be run better,” Martinez said. “I mean, being out there, I understand you have to have quality and precision for this kind of work.”

, a pediatric optometrist at the University of California-San Francisco, said that in addition to experiencing long turnaround times, she has received many glasses for Medi-Cal patients that were broken.

Kane said CALPIA must remake fewer than 1% of orders.

Clarice Waterfield, 64, who lives in Paso Robles, had trouble with her order.

Waterfield has diplopia, or double vision, and an astigmatism that causes her vision to be blurry. She’s a personal shopper for grocery delivery company Instacart, and without help seeing, she said, boxes of cereal and crackers blend together. Grocery store aisles become big, long blocks.

She got her glasses about six weeks after ordering them March 1. She eagerly put them on but found they weren’t the right prescription. They made her vision worse. “You could have held a stuffed animal or something right in front of my face, and all I could see was a big, blurry smear.”

The clinic had to return the glasses and reorder them. After another six weeks, Waterfield received the correct pair. But she remembers the frustration.

“I was like, ‘Are you kidding me?’” Waterfield recalled. “I’ve been waiting too long for these glasses, and now that I have them in my hands, I have to hand them back?”

This story was produced by  (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at  (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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The 73-year-old retired orthopedic surgeon in Fresno, California, knew it was time for cataract surgery. “It’s like car tires wearing out because you drive on them so much,” he said.

In December 2021, he went to the outpatient department of the local hospital to undergo the common procedure that usually replaces the natural eye lens with an artificial one and is designed to restore vision. The outpatient procedure went smoothly, and Manimtim healed over the next few weeks.

Manimtim, who since retiring took a job evaluating disability claims for the state of California, knows the health care system and keeps tabs on his health benefits. He knew he already had met his health insurance deductible for the year, so he expected a manageable out-of-pocket expense for the surgery. He calculated his coinsurance would be about $750.

Then the bills came.

Patient: Danilo Manimtim, 73, of Fresno, California. He is insured through his employer by Anthem Blue Cross of California for outpatient care and is covered by .

Total Bill: Overall, the charges were $9,084 for surgery, anesthesia, medical supplies, pharmacy, and clinical laboratory services. Anthem paid $5,027 and initially billed Manimtim $4,057.

Service Providers: . It is part of Trinity Health, with 88 hospitals and 125 urgent care centers . The hospital system brought in nearly in revenue for the most .

Medical Service: Cataract surgery as an outpatient, involving anesthesia.

What Gives: Manimtim’s big bill stems from a simple decision that turned out to be a pitfall in the nation’s complicated health care system: He scheduled his surgery at a nearby hospital — a hospital that happened to charge about $7,000 more for the procedure than his insurer would pay.

Manimtim has proof that it could have been different right under his own roof: Four months later, his wife, Marilou Manimtim, 66, got the exact same procedure at an outpatient eye care surgical center in Fresno called . It is a half-mile from Saint Agnes Medical Center but is not affiliated with the hospital.

Both patients have the same insurance coverage through Anthem Blue Cross of California; they had identical cataract surgeries; and both providers were in Anthem’s coverage network. Marilou owed $204, while Danilo was on the hook for a staggering $4,057.

“This is ridiculous, and it feels very unfair,” Danilo Manimtim said. “How can it be so much more expensive than the surgical center? It’s walking distance away, and if I would have gone there, I would have saved myself a lot of money.”

Manimtim’s insurance plan, via his employer, the California Public Employees’ Retirement System, caps payment for outpatient cataract surgery at $2,000, according to Anthem. CalPERS instituted a , in which it determines a reasonable price for a high-quality procedure of that type in California. It then reimburses only up to that amount, encouraging patients to shop for treatment priced under the bar. For the cataract surgery itself, patients in Manimtim’s plan are on the hook for any charges above $2,000.

Even for hospital-based care, Saint Agnes’ overall charges are high for cataract surgery, said Dr. , chief medical officer for , which analyzes health care prices for employers. “The hospital charged three to four times the amount of what this surgery typically costs, which is around $3,000.”

“Nobody gets $9,000 for cataract surgery,” he added.

If Manimtim had opted for Medicare Part B, the part of the Medicare program that covers outpatient care, he likely would have been on the hook for only , a Medicare cost comparison tool shows. Medicare pays a set amount for procedures regardless of where they are performed.

But like many older Americans who are still working, Manimtim chose not to sign up for that coverage, instead opting for his employer’s plan because his monthly premium would be significantly cheaper.

Health care prices often have very little to do with the actual costs of providing the care and its quality — and patients often face the “double whammy” of high prices and complex benefits, said Anthony Wright, executive director of Health Access California, a nonprofit advocacy group. Too often, patients are on their own to figure out high prices and complex benefits, he said.

“You wonder what is the rationale for any of the prices in our health care system,” Wright said.

Resolution: After inquiries by KHN, Anthem contacted the hospital, Saint Agnes, seeking help for Manimtim. Although the doctor is responsible for requesting an exemption from CalPERS’ $2,000 limit on payments for cataract surgery under Manimtim’s plan, that didn’t happen before his surgery. Anthem asked the hospital and doctor to consider the request post-surgery, said Anthem spokesperson Michael Bowman.

Saint Agnes spokesperson Kelley Sanchez told KHN that the hospital and provider later requested the exemption that would allow the insurer to pay more than the $2,000 limit and that it was ultimately approved by Anthem. That is expected to leave Manimtim with a much smaller coinsurance bill, around $750 — and get him off the hook for being taken to collections by the hospital. The hospital will receive a higher payment from Anthem, which will cover a large portion of the remaining $4,057 bill.

And that high payment, like all high payments, contributes to rising health insurance payments for all.

Sanchez said the hospital isn’t in the price-gouging business but noted that hospitals generally have higher costs and tend to charge more than outpatient facilities.

“We never want to cause harm or create hardship for our patients, and that extends to our billing practices,” Sanchez said in a prepared statement.

She noted that Saint Agnes has financial assistance programs available and encourages patients to ask questions and understand potential costs before seeking care. “Every patient’s insurance plan is unique so it is their responsibility to understand their plan benefits,” she wrote. “It’s still complicated and we recognize that, and will continue to work toward greater price transparency.”

The Takeaway: The bottom line for patients, experts say, is to be sure to read the fine print of insurance coverage plans to understand all out-of-pocket responsibilities, including premiums, deductibles, copays, and coinsurance. Also, a small number of large employers that self-insure are , putting caps on what they’ll pay for common procedures. Shop around, and ask about prices on the front end if possible.

“People often focus on premiums because they are easy to compare, but premiums don’t tell the full story, and this example illustrates the trade-offs,” said Tricia Neuman, .

Anthem spokesperson Bowman urged patients to use the online Anthem “” to compare patient costs and find a cheaper option if one is available. Had Manimtim done that, he might have seen that getting his cataract surgery at an outpatient surgical center would have been much cheaper. But the details of provider cost and insurance coverage can be idiosyncratic and are often not displayed in a patient-friendly manner. Manimtim did try to explore his benefits before the procedure, he said, but did not get a clear answer from the insurer or hospital.

Manimtim also had advice for consumers: If you receive a medical bill and don’t understand the charges, don’t pay right away. Instead, call your provider and insurer to ask about the charges and whether there are ways to lower your bill.

“People need to be more informed by the insurance companies and hospitals about what options they have, to prevent overbilling,” Manimtim said. “A lot of people don’t know this could happen to them.”

Stephanie O’Neill contributed the audio portrait with this story.

Bill of the Month is a crowdsourced investigation by KHN and that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

This story was produced by , which publishes , an editorially independent service of the .

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