Billing for refraction?

[ADO]

I believe you have to go back and look at what the insurance plans cover. The routine vision plans, like VSP, are there to cover routine visits plus a refraction for glasses. A routine exam includes the 10 elements that NC-OD described above, but does not cover the treatment of eye health issues. The medical plans cover the same 10 elements plus the treatment of any eye health issues. They do not, with any regularity, cover refractions. Knowing this you have to either have a separate charge for your refraction or you have to be willing to give away services. If you bill a medical plan and they say they don't cover the refraction then it is the patients responsibility.
It is very important to know why your patient is coming in. Most patients, and some OD's, automatically assume that when the patients PCP sends them in because they have diabetes they can use their routine vision plan to cover it. That is not the case. This patient is being sent to you for your expertise on a medical issue. This patient should have there medical insurance billed and not their routine. If they have a routine plan they can choose to make another appointment to have their refraction covered or they can save themselves a trip back in and pay the refraction fee. If we continue to bill routine plans for medical issues it won't be long before we are forced to treat eye health issues under routine plans. If that happens then we are all in trouble because their won't be enough OD's around to keep us all employed.
At the last practice I managed we always collected the refraction fee from the patient when we were billing medical. If we were able to get paid on the refraction we refunded the pt.

[orangezero]

Good points ADO.

The problem with all of this is the patients don't really understand their coverage, and its implied that vision plans do cover these types of things by the vision plans themselves.

There is even some trickery about to coerce eye docs into accepting vision plan type reimbursement for these medical issues. Patients generally don't care, its all the same to them.

Vision and Medical Insurances laugh all the way to the bank (with the patient's money) with the providers who dramatically undervalue their services or even give things away for free. Lord knows they are not really cutting any of their profits to help us out. It is almost entirely taken out of the providers pocket, but there is a long long history of this.

I think the only good answer is to drop all vision plans and start having patients take advantage of flex spending and health savings accounts. No big provider catalog to look through means the vision plans loose all their "power."

Like this will ever happen, though. Too many people thing they can play the system without getting taken advantage of.

[ADO]

I think the only good answer is to drop all vision plans and start having patients take advantage of flex spending and health savings accounts. No big provider catalog to look through means the vision plans loose all their "power."


I know an OD who dropped all routine vision plans. He only accepts the medical plans.

Bad news: His revenue dropped to a third of what it was before.

Good news: He was able to work 2 fewer days a week.

Great news: He was more profitable then ever before.

Very gutsy, but overall a great move for him.

[HarryChiling]

Yesterday I had a dude ask me if these new glasses were going to correct his color vision. What are they teaching people in these mandated vision self-diagnosis classes?

Well most of the patients don't have acess to the OD's or OMD's like they do to opicians, secretaries, and techs. Most offices won't pay for educated staff instead they use the old tried and true (yeah right) "I'll teach them myself", but since the OD's or OMD's time is too valuable to wast eon staff the staff just picks up what they can on their own, after a while you will catch your staff telling patients the most asinine things. That's how some of this bull gets out there like "will these correct my color vision". Some where in the US an optician probably right now is telling someone "yes they will".

Chip I agree, I do think that more and more doctors are looking for the diagnosis. When I started the goal of an average exam was get them in get them out (more patients = more money) now it seems the goal is spend enough time with them to find a diagnosis (find something = more testing = more money). Can't say I blame them and on top of it the patients walk away happy, because they truly felt hte doctor spent alot of time wit them and listened. I have seen patients being billed medically for allergies and when I ask if the allegies are bothering them they say "NO" and usually question why I asked (ophthalmology practice).

I say unbundle the refraction, because I'm sure this won't come as a shock to anyone a refraction is not medical IMO, in the isurance companies opinion, in the patients opinion, and probably a few others as well.

[shellrob]

I have an interesting one where the MD billed a medical e/m 99213 ($75) and a refraction ($25). The carrier keyed the claim as $0 for the 99213 and then applied the cost of the office visit to the refraction which they of course denied saying that routine vision is not a covered benefit. They're saying that you can't bill an OV with a refraction b/c they are one in the same... Am I missing something? The dx was Amblyopia.

The person doing the billing made a mistake-simple as that. You need to call and they will straighten it out. It's happened to me many times.

As far as billing refractions, the reason they get denied is because that person doesn't have coverage for vision services. Period. Just like Illanh said.They have a medical insurance that doesn't pay for it. We also bill the refraction seperate as well because they require us to. The only times we ever do JUST a refraction would be if the patient just came from our MD next door and needed an rx for glasses, only exception. I couldn't comprehend any doctor doing just a refraction on a patient. Sounds like a lawsuit waiting to happen.

[orangezero]

I did forget to mention that. Medical insurance companies make more money by denying claims. Simple.

If you bill for an exam and a foreign body removal, they may only reimburse the lower paying fee and hope you don't see they forgot to pay the other. How many times do offices not notice?

Also, there are some plans where you have to bill a refraction to a carrier, get a denial, and then bill to patient. You can't just bill to the patient to begin with. Lots of stupid stuff like that. And each plan is allowed to have different policies.

There has to be a better way.

I bet if patients paid out of pocket for everything and then got reimbursed by the insurance companies after sending in the info, there would be lawsuits and federal investigations within a year because of all the deceit that goes on with their questionable billing practices. Consumer advocate groups wouldn't put up with it.

But the way it is its left up the office staff at the doctor's office, and then they have to pass those extra costs along to their patient's in the form of higher fees.

It just amazes me all the people involved in health care who do nothing but shuffle papers, in both the doctors offices and the insurance companies.

The only hope is computerization, but I doubt it will solve much of anything.

[chip anderson]

I'll bet if asked 90% of those patients with no history of pathology and no symptoms would say if asked: "I just want to get my glasses prescription checked." They would be gratefull and accept treatment if pathology found, but the reason they came was "I just wantto get my glasses prescription checked."
In the past this has always been why the patient was there and what a routine exam was for. Now that O.D.'s can treat and used drops I don't know if they are after higher fees or terrified that the new powers will be resended if one is found lacking on the "thoughness" of his exam.
Were O.D.'s sued daily in the past when they couldn't dillate, use drops, or treat medical conditions?
Were they sued daily when they "jumped the gun" in treating these conditions prior to legislatures granting such powers?
Chip

[ADO]

To back up what Orangezero is saying:

We actually had a big insurance carrier drop us as a provider because we consistently second guessed their payments.
Whatever level of exam we billed they would automatically drop it a level and pay that amount. We would then take the step of re-filing the claim and get it corrected. After about 6 months of this they dropped us saying that we caused them too much work and that other doctors in town accepted their payment methods without question so they were going to refer their members to those doctors.

I wonder how many of the doctors even know they were getting paid less then they contracted for?

[drk]

Some docs bend the rules to "upcode" a routine visit to a medical visit.

Sometimes because it will save the patient short-term expenditure.

Sometimes because it will enhance the doc's reimbusement.


Bottom line is that patients present for:
1.) Medical care
2.) Vision care
3.) Both

and it's up to the doc to determine what the reason for visit is, and who's on the hook to pay.

Routine/preventative care is not universally covered by health insurers, probably to the detriment of public health. Preventative care is an individual's responsibility, as is.

[orangezero]

That is a valid point chip.

However... public perception is that everything can be "fixed" with eyeglasses. Commonly it can and these are the times you are thinking of, but there are very common issues that can't be. And more importantly, even if a patient has every systemic and eye disease in the book, they still present for "just want glasses." And then either during the history or during the exam it will come up that they have dry eyes, uncontrolled hypertension, untreated glaucoma, and a diabetic retinopathy. But just fix it with glasses, please.

And another point worth mentioning: things have changed since the 1950s, 70s or even the 90s. For example, back "in the day" patients went blind from glaucoma. Now we have some tests that can detect and delay or prevent symptomatic visual complications.

Medical providers in this day and age don't have the option of practicing "1950s style standard of care."

When is the last time you had someone come in your shop and say, "gee, I don't see that well, perhaps I have glaucoma?"

I don't think optometrists perform additional testing out of fear of loosing their legal rights. Most malpractice cases involving optometrists have traditionally involved failure to perform procedures that an optometrist (or ophthalmologist) would do in a similar situation and that causes the patient harm from the lack of care. Perhaps more of a CYA than anything, but I think its just silly to think someone who give up years of their life just to screw over patients. So many other ways to make money in life besides health care (unless you are involved with providing coverage I guess).

You'll laugh at this I'm sure, but dry eyes is the one of the number one reasons for the elderly contemplating suicide. Chronic issues are no treat to live with. Be careful what you downplay at superfluous.

To summarize:
Patients don't (and aren't expected to) understand what is involved with their visual symptoms. It is the optometrist's or ophthalmologist's job to figure out the reason actually is even if it can't necessarily be understood by the patient, although I would hope it could be explained to patients in an easy to understand way. It can be refractive related or medical related. Society has placed a larger value on dealing with those medical issues. I'm sure you can understand why anyone would prefer to be paid for what they do, instead of what is cheapest for insurance companies.


Another interesting point. Virtually no patients even know that a medical eye issue is covered under their medical plan they already have, they think its covered under their vision plan. Why is this?

[orangezero]

ADO,

I've personally seen several area ODs undercharging on a consistant basis to "avoid an audit." So, they are basically getting underpaid for all of their services. There is quite a range, but my general feeling is that medical eye care has been done for essentially free for so long that now that we actually have the legal rights to submit to a patient's medical insurance it just seems odd. I can certainly understand the confusion, but the condemnation of getting paid for what practioners do is silly, IMO.

Generally, insurance company hot-line lines are staffed by people following orders, often incorrect orders. Its just stupid they can't follow their own rules.

And Drk, probably a more succinct summary than me!

[ADO]

Orangezero and Drk,
If I ever get back in the private practice side I am looking you two up. Very refreshing to see doctors take responsibility for having the money conversation with their patients. Too many times I have seen it left to the young receptionist who is clueless on how to handle it. It can be an uncomfortable conversation, but if you handle it correctly it is usually not a problem at all.

Great job to both of you!

[chip anderson]

Anyone remember when doctors got patients by referral from satisfied patients? Insurance just paid 80% of the bill.

Does this mean that elderly sucide could be prevented by the simple cheap application of castor oil drops?

Gee, we can have fun with this post.

[1968]

You'll laugh at this I'm sure, but dry eyes is the one of the number one reasons for the elderly contemplating suicide.

I'm skeptical. How many number one reasons are there?

Patients don't (and aren't expected to) understand what is involved with their visual symptoms. It is the optometrist's or ophthalmologist's job to figure out the reason actually is even if it can't necessarily be understood by the patient, although I would hope it could be explained to patients in an easy to understand way. It can be refractive related or medical related. Society has placed a larger value on dealing with those medical issues. I'm sure you can understand why anyone would prefer to be paid for what they do, instead of what is cheapest for insurance companies.

I agree with this. In my (biased) opinion, 92015 should be a covered service in that the underlying reason for "blurry vision" frequently cannot be determined without it.

[orangezero]

there are 17 number one reasons, duh!@@@

oops. my mistake.

The point of the lecturer who was making the point was not that we are saving seniors from commiting suicide, but rather that it is a bigger issue than most give it credit for. Dry eye has long been poorly treated and a lifetime of patients have been silently suffering with it because they didn't know it was something that could be dealt with. I know for a fact I've never saved a senior patient from suicide, but it has made me ask about dryness more than before.

And the causes and solutions to dry eye disease (anterior surface disease, what have you) are only now starting to be adequately addressed. The answer isn't simply to have the patients insert castor oil drops 15x per day, because there are better ways to deal with the cause of it, not just the symptoms. Its not just the dryness, but also the redness and irritation, and sometimes the social stigma that goes along with it.

But you do have to go out on a limb and say our tear production system, our eyelids, and our cornea are a part of our body and if they aren't working correctly it actually is a medical condition/disease. Previously, practitioners did just give drops and "next please." Perhaps that wasn't worth a whole lot back then, but once again times are different.

Which do you want Chip? Do you want us to spend more time with patients and solve their problems, or do you want to do whats cheapest and what you've always been accustomed to? Its not making money out of thin air, these patients have problems and we now have solutions.

How dare we expect them to pay for our expertise, is that what you are contending?

I just knew that dry eye thing would get comments :idea:

[chip anderson]

Actually Castor Oil four times a day will cure almost every case of keratitus dissicica eventually.

Where did I get this? From Dr. Louis Girrard, M.D.

Where did he get it? Back in the late 50's and early 60's anesthesiologists were using anesthesia that kept the patient's eyes open during non-opthalmic surgery. They didn't like the patient's corneas cracking so they
carried Castor Oil and dropped it in, the patient could be kept out for hours without corneal damage. Dr. Girrard started trying it on the worst cases of keratitus dissicca which were sent to him while he was chief of Baylor Medical's Ophthalmology Department. It worked.

Why doesn't anyone prescribe this? It's not FDA approved as it's not patentable. Today's doctors are far more afraid of lawyers than intersted in the patient.

Chip

[orangezero]

Endura?
Restasis has castor oil?

I don't doubt you or the doctor you mention. However, a perfectly "normal" patient who is having their eyes held open and requires some type of tear shield is a bit different than the numerous other ways patients are affected with what the layman would term "dry eye."

What castor oil are you recommending to your patients?

Honestly Chip, your distain for the average doctor is disheartening. We have feelings too (even the nonMDs you don't consider doctors). The real heartless, out for profit, dudes are in other businesses swindling you out of even greater amounts of money on a daily basis. So many betters ways to bring home the bacon that medical care.

[chip anderson]

Orange: I don't make any money if the doctor recommends castor oil, the doctor doesn't, the drug store doesn't appreciably, and for all practical purposes the patient has no expense. While the little drug detail girl in the miniskirt does make a tempting presentation for restasis, it fails and castor oil doesn't. Now I don't know how money and greed got into this, as the preventative mentioned was fear of lawyers.
But why Rx things that only work from the chair to the parking lot when the cure has been around a long time, cost next to nothing, has no adverse effects, and actually work? Of course I admit that doctors must get a lot of pressure from patient's seeing direct to the public drug commercials and asking: "Doctor can I take this?"
Doctors must hate this.

You may not recognise this, but I am trying to help you with this, if you are patient motivated.

[shellrob]

Orange is right, the majority of patients think that any visual problem they are having will be fixed with glasses. We all know this isn't true. That's why one cannot do JUST a refraction. That's a major disservice to your patients. So, if they come in JUST to get an rx for glasses and tell you they don't want the "other" parts of the exam, and you find a cataract-you won't tell them because that's not what they're there for? Give me a break. Some people on this board think that doctors(specfically od's) are just out to make money. Give me a break. I'm not saying therer aren't some out there like that, but their not ALL like that. I think that O'd are highly underpaid for treating some of the same things Mds treat.That's a fact in itself and some od's just want to get paid the same for the same treatment. Rightfully so.

[orangezero]

Correct, not a fan of direct-to-consumer advertising. Don't know many who are.

I'd prefer not to get too wrapped in the whole money/greed issue myself, sorry to go there.

I'm curious why you think restasis doesn't work?

I haven't checked in store (you've got me curious), do you tell patient's to get the stuff on the shelf you use for vomiting?

[HarryChiling]

Orange is right, the majority of patients think that any visual problem they are having will be fixed with glasses. We all know this isn't true. That's why one cannot do JUST a refraction. That's a major disservice to your patients. So, if they come in JUST to get an rx for glasses and tell you they don't want the "other" parts of the exam, and you find a cataract-you won't tell them because that's not what they're there for? Give me a break.

Just out of curiosity what are these conditions that only a refraction can pick up? GIVE ME A BREAK. That's the excuse used to make sure opticians never refract not an actual truth.

The arguement has always been if the refraction is split from the exam then no one will want to get an exam they'll all want refractions and yes people do think that glasses will solve everything, but OD's have historically been the ones to prescribe glasses so where along the line did OD's drop the ball.

The medical arena has just now opened up to OD's so now everyone needs to focus on the medical side of things. Wouldn't it be correct to say that 50 years ago the medical eye exam was just as important as it is today.

[MarcE]

Wouldn't it be correct to say that 50 years ago the medical eye exam was just as important as it is today.

No, it would incorrect to say that. It's more important now because

1. The standard of care is greatly increased and more precisely defined, therefore,
2. The chances of being sued have increased many-fold, and most importantly,
3. The treatments available now can prevent diseases and greatly enhance quality of life like couldn't be done 50 years ago.

50 years ago, the public didn't care for or pay for preventitive exams or care. Now things have changed. The general public wants and is willing to pay for preventative health exams.

Yes Chip, things have changed. OMDs don't go to school for 12 years at a cost of $200K and a forgone income of another $500K just so they can bill $39 for an exam including a refraction. But gasoline isn't $0.29/gallon anymore either.

[HarryChiling]

No, it would incorrect to say that. It's more important now because

1. The standard of care is greatly increased and more precisely defined, therefore,
2. The chances of being sued have increased many-fold, and most importantly,
3. The treatments available now can prevent diseases and greatly enhance quality of life like couldn't be done 50 years ago.

50 years ago, the public didn't care for or pay for preventitive exams or care. Now things have changed. The general public wants and is willing to pay for preventative health exams.

Yes Chip, things have changed. OMDs don't go to school for 12 years at a cost of $200K and a forgone income of another $500K just so they can bill $39 for an exam including a refraction. But gasoline isn't $0.29/gallon anymore either.

Let me rephrase then how about 10 years ago? The point I was trying to get across is that now that OD's do have the right to bill medically doesn't mean the world has all of a sudden changed. Before the medical billing I remember that OD's pushed for more exams through the door now that may have meant missing more pathology, but that was how things were done, now with medical billing the idea is spend more time with the patient and if you find a diagnosis jackpot.

Now all said and done yes I enjoy this way a whole lot better than the old, more time spent with patients and less diagnosis missed a great thing indeed, but it should have been this way 10 years ago or 20. The standard has gotten better I agree, but to say that the old standard wasn't adequate would be false. Now if this way of thinking were to continue if OD's were to be allowed to perform LASIK, then all of a sudden glasses and contacts would be the old way of doing things and no longer recommended. That would be the outdated standard of care.

The scope of p[ractice of an OD has increased and now this is the growing pains that unfortunately go along with it. The general public doesn't want or think they need this service, because in the past they have come to the very same doctors and not recieved these services so they don't see the value on them. I would have to say that sometimes I don't either, for instance OK you found out the patient has dry eyes, you give them something to help, but the difference now is you want to see them back and you bill medically for this second visit. Before you would give them the drop and be done with it. In some cases when they come back if it didn't help you try something else and this creates a trough that everyone feeds from. Then when my insurance premiums go up, because all of a sudden theirs another hog in the trough.

This will enevitably lead to lower reimbursements from insurance companies whihc will then lead to OD's needing to expand their scope again. It's an endless cycle, but the whole idea of the level of care getting better is pure crap when in the end the optical which is where most end up purchaseing corrective devices is still the area most ignored. Sure perform a spot on exam testing for everything under the sun with the latest and greatest in equipment all while the person operating this equipment has less at best a high school education and the person dispensing the devices to help correct the most commonly prescribed devices from the office (contacts and glasses) doesn't have a clue what they are doing.

The standard hasn't changed the the way in which they get payed.

[chip anderson]

Orange:
I have seen many, many patients who found that restasis didn't work or provided only momentary relief. Castor oil isn't for vomiting it's to cause things to pass through the bowel. And yes, the stuff on the drug store shelf is the same stuff. The stuff in the paint store is toxic.

In the fine print you will find that restasis provides only temporary relief, not a cure and it lowers one's immune capabilty to infection, castor oil does not.

Wouldn't you like your patient's to tell other patients that you were that wonderfull doctor that told them about this. Cured them of the problem and they didn't require and Rx and it cost next to nothing. Above all it worked.

I'm not sure how it works for you professionals but as a non professional and as a suggestion for which no fee is charged, one is not practicing medicine or optometry. Just being a helpful friend.

Chip

[rdcoach5]

Chip, how often and what brand or strength castor oil did the Dr use. Was it specially purified or distilled? I would recommend it for a co-worker but I doubt I could convince her to try it.:finger:
Bob Taylor