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 By Neil B. Gailmard, OD, MBA, FAAO, Editor October 6, 2004 - Tip #142 
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Are your fees for an emergency office visit high enough?


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Many of my Management Tips of the Week will immediately increase practice income if put into effect, and this one definitely falls into that group. The tip is to re-evaluate your fee for an emergency office visit, and make sure it's commensurate with the value of the service provided. I find that urgent office visits are often set too low in many optometric practices, and I'm referring to exams that occur during normal business hours. After-hour care would be even higher, but I won't cover that in this tip.

These fees are probably set too low because the optometrist thinks of the office visits as intermediate exams, or even brief exams. In truth, they generally don't meet either of these descriptions. But the usual thinking is that these exams are for established patients in the practice who are not yet due for a full eye exam including refraction and fundus exam, but they probably have a red eye of some kind. That may be true, but it shouldn't trivialize the care you provide in these cases. In my opinion, an exam for an urgent eye problem should command a fee at least as high as a comprehensive eye exam, and quite possibly much higher. The emergency office visit usually takes longer and is more difficult than a routine comprehensive eye exam. If you often charge a lower fee for office visits to investigate an ocular problem, this tip is written for you.

This is a good spot to mention that many practitioners have their fee for a comprehensive eye exam also set too low, so that may not be the best guide as to what to charge. Let me point out that the Medicare fee schedule sets a 92004 at over $120. I could go on about raising fees for services in general, but I'll keep the focus on emergency visits.

Supporting the higher fee

Here are a few reasons why a high fee is appropriate for urgent exams.
  • The medical decision-making and the responsibility for proper care are very high.
  • Red eyes are never simple - there are dozens of possible diagnoses and they can be sight threatening. The same goes for eye pain, vision loss, light flashes, trauma, etc.
  • Because red eye and other sudden ocular complaints are not always what they appear, a thorough exam is indicated. It would be a mistake to not measure IOP and examine the fundus in a red eye complaint, and often the pupil needs to be dilated. Acuity is always measured and you may conduct an autorefraction or subjective refraction to rule out optical influences on acuity. So, a brief exam should not be the normal protocol. If you delegate well, however, a thorough exam need not take an extreme amount of doctor time.
  • The office schedule must be rearranged to accommodate an extra appointment. Doctor, staff and other patients are all placed at a disadvantage in order to see the emergency patient.
  • The alternatives to a patient with an emergency eye problem are very limited and expensive. Ophthalmologists charge a high fee for this kind of in-office care and hospital emergency rooms will be even more expensive.
What about the insurance coding?

The procedure code is what it is and your decision to accept assignment or not is up to you. You can use 92XXX or 99XXX codes and code the service at the appropriate level just as you always do. If you perform the tests that are the standard of care in these cases and bill for them, you'll generate an adequate fee. I don't let insurance companies set my fees and I won't get caught up in a situation where payment is denied by a third party health plan. Our policy is to have patients pay in full at the time of service and they can be reimbursed by their insurance plan. The only exception to this is Medicare.

Our receptionists always discuss fees over the phone and explain our payment policy, whether the patient asks about it or not. We do this for every appointment - not just emergency visits. I feel we have a duty to inform patients of all the things they need to know and I want to avoid a problem at the front desk if a patient is not prepared to pay for services. Patients appreciate being informed of the payment expectations; they need the care and they know it's not free. Our financial policies are firm and no exceptions are made, and it's clear before they hang up and drive over.

What is an emergency?

It's a good idea to print a list of symptoms that you consider to be ocular emergencies for your receptionists to keep handy and to help them properly triage phone calls. Emergency visits generally include all requests to be seen immediately and any eye or vision complaint that is sudden. I have trained my receptionists to respond to emergency calls by saying "How soon can you get here?" Of course we will see any patient (new or established) who has an urgent problem; we will make room in the schedule. We avoid trying to diagnose conditions over the phone.


Best wishes for continued success,

Read Past Tips Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week


A Proud Supporter of

Send questions and comments to neil@gailmard.com.

Dr. Gailmard offers consulting services to eye care professionals through Prima Eye Group; information is available at www.primaeyegroup.com.
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