Provide Medical Eye Care
How to build your practice by identifying what is already in your chair.
JASON R. MILLER, O.D., M.B.A., F.A.A.O., POWELL, OHIO, AND WALTER O. WHITLEY, O.D., M.B.A., F.A.A.O., NORFOLK, VA.
A total of 17% of an O.D.’s practice revenue is derived from medical eye care, says Alcon and Essilor’s Management & Business Academy. Considering our training and skills in the diagnosis and management of ocular disease and the fact that many of our patients need medical eye care, this number should be a lot higher. In addition, focusing on medical eye care may be the key to our profession’s survival, based on the continuous growth in the baby boomer population (an increase in age-related eye disease), the passing of the Affordable Care Act and retail optical competition.
Here, we explain the four ways you can identify patients who require medical eye care.
1 Perform the standard of care.
Increasing the amount of medical eye care primarily results from a thorough comprehensive exam and understanding the prevalence and risk factors for various eye conditions. Nonetheless, the patient’s reason for their visit, or “chief complaint,” is the basis for the encounter and determines which insurances or party is responsible. During the history, examination and testing (based on medical necessity), there are many signs, symptoms and risk factors that may be detected to warrant further investigation. When they are detected, an order for additional testing or a problem-focused exam should be documented in the plan, and patients should be scheduled accordingly. (See “Which Insurance Do I Bill?” page 34.)
Which Insurance Do I Bill?
The patient’s “reason for the visit” determines which insurance is billed. So, if a patient presents with a refractive, non-medical reason for his visit, his vision plan receives the bill for the encounter. If the patient presents with a medical complaint, such as “here to get my diabetes checked,” his medical insurance receives the bill for the encounter. If he presents with both, we may coordinate the benefits from both insurances (if there is a provider for both) for services rendered.
Another scenario: If a patient presents for a vision exam and requires a spectacle prescription update, his vision carrier gets the bill for the encounter (ex. 92xxx or 99xxx — depending on the contents of the medical record — + 92015 would be billed to the vision plan). If you order medical testing during that visit, such as fundus photos (92250), if medically indicated for diabetic retinopathy, his medical carrier may be billed for that testing only (92250).
This is one scenario, but it is also acceptable to have the patient back at a future date to monitor his diabetic eye health and perform any additional medical testing if indicated. (Ex. order procedure: diabetic work-up, including fundus photos, in three months). That order from the patient’s previous encounter becomes the reason for the visit when he comes to the office for that testing.
Many different scenarios may occur, however, the reason for the visit determines which insurance receives the bill for the encounter.
Regardless of the scenario, a front-staff member should discuss this with the patient prior to the visit. This way, patients understand the difference between their insurance plans at the outset, preventing any potential confusion or patient complaints, while also educating them that you provide both vision and medical eyecare services. We recommend explaining the “why” to every patient when we “order visits and/or procedures” for them. This helps patients understand the differences between medical necessity and vision examinations. Patient education forms that show the difference between the two insurance types also help improve patient understanding of why a particular carrier is billed.
By simply focusing on the patient, you’ll start to build your medical care from within your practice and see an increase in practice revenue. For example, many patients who present with ocular surface disease present for an exam with a history of dry eye disease (DED), which they have already been self-treating with no relief. If you suspect/identify DED, educate them about their condition and the impact it has on their ocular comfort and overall quality of vision. Let them know the importance of further evaluating their condition using advanced diagnostic technology and treatments and the significance of follow-up care. (See “What You May Be Missing,” page 37.)
2 Integrate necessary technology.
Using your EHR system, search for (data mining) common diagnoses or patient segments that may benefit from specific diagnostic technologies and treatments. For example, a prevalence of patients age 70 and older may suggest you acquire a fundus camera or SD-OCT for the diagnosis of retinal disorders, such as AMD.
Evaluate the current trends and prevalence of the various disease states to see how you compare. Is your practice-incidence pattern lower than these averages? If so, numerous patients may have been overlooked for the condition or just not followed because the respective diagnostic/therapeutic technology wasn’t available. Then, perform a breakeven analysis to see how long it will take for you to pay off the technology. If it doesn’t add up, consider co-ownership of technologies, or comanage with an O.D. for special testing services only.
What You May Be Missing
The following is a list of the most prevalent medical eye conditions, keeping in mind that the median patient volume for an optometry practice is 3,100 patients per year.
1. AMD. Using the liberal definition of AMD (i.e., all patients with significant drusen in the posterior pole, with or without visual loss), it is estimated AMD prevalence is greater than 20% of the population older than 60 years. A more rigorous, population-based survey with a definition that requires the presence of either late atrophy and/or choroidal neovascularization results in an incidence of 0% at age 50 years or younger, 2% at 70 years, and 6% at 80 years, says a MedScape article. Using the prevalence of 20% of patients older than age 60 and the fact that the average amount of AMD-related visits per year is two (but again, this is determined by medical necessity), the annual practice revenue for AMD would be $90,520 for visits alone. If you factor in OCT ($46.21 per test) and fundus photography ($79.17), this figure would be even higher depending on the frequency of testing.
2. Dry eye disease (DED). An overall summary of data suggests that the prevalence of dry eye is somewhere in the range of 5% to 30% in the population aged 50 years and older, says the 2007 Report of the International Dry Eye WorkShop. If we also take into account patients who may suffer from ocular discomfort from contact lens wear and allergy patients who may suffer from DED, this number may be even higher.
Let’s say the incidence of DED in our “typical” practice is 25%. That means roughly 775 of your patients have DED. The average reimbursement per visit for these patients is $73. (This figure is for illustration purposes only, based on the Medicare Allowable fee for code 99213.) The average number of DED-related visits per year is three (but this is determined by medical necessity), bringing the annual practice revenue for DED to $169,725 for visits alone. This dollar amount does not include additional procedures and products that can be used to maximize treatment. For example, temporary and permanent punctal occlusion can add additional revenue of $229.44 ($152.96 for first plug, $76.48 for each additional plug) per patient.
3. Ocular allergy. Ocular allergies are often underdiagnosed and undertreated. In an older patient population, the prevalence of ocular allergy is 15% to 20%, but more recent studies reveal rates as high as 40%, according to October 2011’s Current Opinion in Allergy and Clinical Immunology.
If we used a 20% prevalence rate, about 620 of your patients have this condition. The average reimbursement per visit for these patients is also $73, according to Medicare fee data. The average amount of ocular allergy-related visits per year is two (but again, this is determined by medical necessity), making the annual practice revenue for this condition $90,520 for visits alone.
4. Glaucoma/ocular hypertension (OHTN). The incidence of glaucoma is 2%, while the frequency of OHTN is 8%, according to recent studies in Archives of Ophthalmology. That means an average of 310 patients in your practice have either condition. The average reimbursement per visit for these patients is $73 as well. The average amount of glaucoma-related visits per year is four (again, this is determined by medical necessity), bringing the annual practice revenue for these conditions to $90,520 for visits alone. If you add special ophthalmologic testing for glaucoma, however, you’d add another $314.88, which includes OCT ($46.21), pachymetry ($15.40), gonioscopy ($27.94), threshold visual fields ($65.20) and fundus photography ($79.17). The frequency of any of these tests in a given year is based on medical necessity, and some insurances may have their own frequency limitations. Also, keep in mind that more patients than are mentioned may be at risk for these conditions due risk factors, including high IOP, cup-to-disc ratio, family history, age, central corneal thickness and race.
3 Educate staff.
Your staff helps to not only perform medical eyecare services, but also to educate patients on the importance of these services and the fact that you provide them. Numerous educational opportunities exist, such as bringing them into the exam room, holding staff meetings, in-services with various drug or device representatives and eyecare-themed meetings.
4 Market your services.
Every patient encounter is an opportunity to educate patients on what we do. Prescribe drugs, perform procedures, and coordinate care to medically manage them. Provide in-office brochures and posters on the medical eyecare conditions you can diagnose and treat. Brand items with your practice name and logo to reinforce your role as the medical eyecare expert.
Other marketing ideas: Highlight your skills on your practice website and on-hold message; participate in community events, such as school screenings; and become active in your local, state and national associations, which also help educate the public. Lastly, get involved in the political process: Many legislators don’t understand the O.D.’s role in healthcare.
Dollars and sense
We are highly trained in the diagnosis and management of ocular disease, so let’s start identifying these patients. Practicing to our fullest scope not only increases practice revenue, as illustrated above, it also betters our patients’ lives and the profession as a whole. OM
Special thanks to John Rumpakis, O.D., M.B.A. for his help on this article.
Dr. Miller is a partner in a private practice in Powell, Ohio, and is an adjunct faculty member for the Ohio State University College of Optometry. E-mail him at firstname.lastname@example.org, or send comments to email@example.com.
Dr. Whitley is the director of optometric services at Virginia Eye in Norfolk, Va. E-mail him at firstname.lastname@example.org.