An O.D. in the area is sending postcards to seniors with medicare saying,"Come in for your eye exam it is FREE with Medicare all you have to do is pay a 15 dollar co-pay." This seems like the O.D. is guaranteeing he will find something billable. Is this ethical? legal?:o
Whats the problem? The guy is just trying to make a buck.
The problem is that the O.D. is practically guuaranteeing that a medical problem will come up and will rip off Medicare for pay. Or are you cool with ripping off everyone's Medicare. I see you are retired and are already receiving this benefit already so you probably do not care. however I am tired of the system being bilked by false "medical findings"
From a statistical standpoint it would be highly unlikely that a geriatric patient not have any age related eye changes (arcus seniles, cataract changes, floaters, corneal haze). Early detection of age related eye disease, glaucoma and systemic disease is important. Many 65 y.o. + patients wait years between eye examinations and part of the reason can be financial. If the doctor is willing to take assignment and provide a needed service then I see no problem with it.
I suppose that the "ethical" thing to do would be to have a disclaimer on the actuall card stating that medicare will only guarantee payment if a medical reason is found for the visit. It really only gets unethical when he bills for something that isn't really there. Funny that it is coming from an OD not an MD.
lab fly said “I see you are retired and are already receiving this benefit already so you probably do not care.” Don’t care ! ! ! With the confiscatory taxes that I am paying to support this system, you had better believe I care.
If you have evidence to support your accusation of malfeasance you are quite remiss in not going to your State Attorney General. If you do not have any evidence you might want to reconsider busting this guys chops here on OptiBoard. Maybe the poor guy is happy with the $15.00 fee and is not billing any third party. Perhaps he sees a need in the community and is doing a little bit to charitable work.
In any case, go to your room and think about it. If you would not make these accusations of “ripping off Medicaid” to the OD’s face, please do not make them behind OptiBoards skirt of anonymity.
Originally Posted by lab fly
So, he's not charging for refraction then?
I'm sure the actual wording makes a big difference. Is the grammar really that poor?
Hmm, are we...
Jealous ?
There is no set co-pay with conventional medicare-only the $100.00 deductible per year. This OD MUST bill Medicare first and get paid or rejected for the service. Then he/she MUST bill the patient for any deductible amount or copay. Waiving the deductible or the copay is against the law. This doc sounds new to the system.
since most medicare patients will have met their deductible by now, he is probably using the $15 amount as the 20% copay..
I have head many people suggest this same tatic for increasing business during 4th qtr...
Cassandra
"Some believe in destiny, and some believe in fate. But I believe that happiness is something we create."-Something More by Sugarland
The patient has to have a presenting medical complaint if Medicare is to pay for the eye exam.
If they come in and say they are in for "a routine exam for glasses", it is not covered even if you find cataracts, mac degen or glaucoma. Next visit is covered, but not the first routine exam.
I think his $15 copay is meant for the refraction, so he half understands the rules.
Medicare does not even cover a routine physical medical exam without medical complaint.
In summary, our friend with the mailers is going to ruffle some feathers and someone will probably report him to the state optometry board.
Harry
The only issue here is that 15.00 does not equal free.
Doc: Most to the bove mentioned in parenthes above are norman aging things like gray hair and wrinkles. No treatment is required. Does this mean that the poor unsuspecting taxpayers (I think they are the "free" mentioned in the add) will pay for the doctor to see an arcus sinlus?
Other than having to match one when making a prosthesis what does one do with a diagnosis of arcus sinilus, or floaters or corneal haze or even early cataract changes?
One should pay a doctor's fee to be told: "You old, boy."
Maybe the doc is sending out recall cards to pre-existing patients that are already known to have ocular pathology. So he can make the statement that the visit is covered by medicare...All the facts in the case are not layed out. No one should put part of the story into a thread and then ask the rest of us if it is ethical. Who knows?
Anyway, Happy Thanksgiving Everybody.
Chip, I did not mean to imply that "normal" aging changes should be paid by the taxpayer. The point of my comment was that geriatric patients tend to have higher incidence of ocular health problems as compared to the other patients. Because of this I could understand the thinking behind the OD's advertisement.
I leave it up to the physician who made the diagnosis to monitor the condition as needed. Is there a diagnosis code in W. Va for "You old, boy"?
We all know the oldsters have medicare billeable pathology.
But it's only billeable if they know before the start of the exam.
Harry
They have to know what it is? Don't they just have to have a complaint that turns out to be medical?
"blur" can be medical...
From the sounds of this post my thinking might be off base so feel free to correct me.
I was under the impression that Medicare covered an annual eye health exam that does not include refraction. If the doctor does a refraction then the Dr. is to charge a refraction fee.
For what I have seen in Florida (We have a huge elderly population) it is normal business practice to see Medicare clients every year and bill with appropriate diagnosis codes. Is this some sort of fraud? What about routine medical care? Is Medicare only supposed to be involved if the patient has an illness? Seems like that would be counter-productive.
All the talk about tax money seems off base as well. Doesn't most of the Medicare covered population pay (or did pay) taxes? It's not like they just landed on the planet and now we're paying for their eye exams.
I'd be interested to hear some OD's thoughts on my question.
He's only following the advice of experts, although not executed perfectly.
Don't ask what you can do. DO what you can do. -My Paternal Grandpa
I think the point is, "routine" is not covered. "medically necessary" is. Many different definitions of what those things mean. Patient and even practitioner perceptions may be very different than medicare's perceptions of what is appropriate or legal. Guess who wins in an audit?
I can understand maybe feeling a little annoyed at elderly people who have these "free" benefits now, but in all reality they aren't free: they've most likely lived their whole lives working to pay these taxes too and are FINALLY getting something back... as much dang money that comes out of my checks every other week I better see something in return when I'm 65! LoL. :o
Anyway, this is a good question for Medicare, because no one truly understands their policies but them... (IF that!)
The term "blur" can get you in trouble as it suggests a need for refraction, better to use/document the term "loss of vision" which suggests the need for a medical exam. At least that's what the medicare coding gurus say.
Harry
I am not at all sure anything paid for by medicare, or insurance or any other than the person making the offer can be termed "Free."
In fact I think the whole concept is why our incomes average 55% in taxes.
Chip
have you found that out from personal experience with vision plans? Or just from talking with the gurus?
In other words, have you had a cc of blur rejected even though everything else is "complete", and then changed the cc to "loss of vision" later and they accept?
I ask, because I've never really used "blur" in regards to medicare, but have always been told its ok as long as all your other ducks are in a row (history, decison making, etc). I think their point was in highlighting the point of the blur or loss of vision.... Now, if you wrote "glasses not strong enough" or "lost Rx" I could see where that could get you into trouble with the medical insurance..
thanks,
I am not here to put out dirty laundry. I am asking if this is legal or not. I am not going to use this as testimonial in court or any ignorant thing like that. I am asking and appreciate all input.
So far it seems legal. Ethical maybe not. Second this O.D. a.k.a. "poor guy" has been known for some questionable dealings and is NOT happy with just the $15.00 and is not concerned with looking out for the best interest of the community. In conversations with him and his wife I believe the word "hicks" was the word referred to people in this area. As far as saying something to his face I intend to as long as I know for sure I know what I am talking about and have my facts straight.
I am not jealous. I have a real interest in the people in my community and my gut tells me that something here is skirting the ethical treatment of patients. If i have a cold and I go to the doctor he doesn't go out of his way to find a billable disease that could pay more. I see a "blur" in the system and we could argue ethics all day. Just my opinion.
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