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 By Neil B. Gailmard, OD, MBA, FAAO, Editor January 30, 2008 - Tip #313 
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Routine Vision Exams vs. Medical Eye Care


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Topic ideas for tip articles continue to be sparked by reader emails and I greatly appreciate the interaction. In Tip #311, I cited several scenarios that frequently occur in eye care offices that can upset patients. The area of greatest interest is in the differentiation between routine and medical eye care. I think this topic deserves a great deal of attention because it is one of the strongest trends in practice management, but it has the potential to damage patient relationships through misunderstandings.

Vision or medical?

Here is one scenario I described from a patient's point of view:

They told me my vision insurance would cover my exam, but when I got there they said they had to bill my medical plan. I think it's just a way for them to make more money.

That statement prompted this question from a reader that accurately describes the dilemma that many eye care practitioners (ECPs) face every day:

What is an OD to do when he or she discovers a non-threatening sight/ocular condition that does require evaluation, education and management (limited management at the very least) of the patient? They came in expecting the lower vision exam fee yet now they should be "upgraded" to the medical level. Of course, a variety of insurance scenarios can occur: the patient has both vision and medical insurance, no vision or medical insurance, vision plan but no medical insurance, medical insurance but no vision plan, or the worst of all: super high deductible with an MSA/HSA?

My reply:

My opinion may differ from many ECPs on this issue, but I think every exam should include some evaluation, education and management. If the only diagnosis is astigmatism, you had to detect it, measure it and decide how much of it to prescribe. You should tell the patient what astigmatism is and what to expect in the future. You may have to explain further, such as telling him that reading in the dark or watching TV won't cause astigmatism to increase. You may discuss when to wear eyeglasses and if contact lenses are an option. I don't find that kind of work any easier than diagnosing dry eye or mild allergic conjunctivitis and managing those conditions. Patients don't see any difference either.

I don't need to look hard to find a medical diagnosis because my fees are the same whether the case is visual or medical (see next section below). I just do an eye exam and I cover and treat everything I find. I see some medical cases that are extremely easy and fast and I see some refractive cases that are very complex. One comprehensive exam fee still applies in either case and it all averages out in the end. Of course, if I truly need an additional visit for more testing, or a special diagnostic procedure, or a follow-up visit to monitor a condition, I'll order it and charge for it. Those fees may be billed directly to the patient or to any third party plan the patient wishes as long as my office accepts it.

I don't change the exam fee based on whether it's routine or medical. An important point here is that I didn't lower my medical exam fee to the routine level, but rather I raised the routine fee to the going rate for medical exams. I believe ECPs are incorrect with the usual assumption that they will lose patients if they charge a high fee for routine exams. Of course, if the patient has a vision plan, my usual and customary fee will not be covered in full, but that's a business problem that I accepted when I signed up for the vision plan. Finding a medical diagnosis and increasing the fee looks too much like bait and switch to the average patient, and that's very bad for business.

If I'm ever unsure whether to bill a vision plan or a medical plan (assuming the service is covered by both with no clear coordination of benefits), I'll ask the patient which one he wants me to bill. I'm also never shy about charging the patient privately and letting him file his own claim. We tell patients over the phone in advance what the fee will be and we discuss their insurance and advise accordingly if they will be expected to pay at the time of the visit. They don't mind; quite the contrary... patients appreciate knowing what the fees will be.

No surprises

In Tip # 311, I wrote:

Patients hate surprises about fees. Tell people in advance what to expect.

A reader responded: This would be interesting to expand on. What is a surprise anyway?

My Reply:

Of course, only the unpleasant surprises bother people. Examples would include situations when the patient didn't know that a fee would be charged (a contact lens evaluation, perhaps) or when the fee is higher than expected. Another unpleasant surprise would include not being able to use the insurance plan the patient intended to use. Patients view insurance as an extension of their own personal resources and they want to maintain control over it. They generally pay something for the insurance or earn it as part of their employment. Patients may prefer to use one plan over another for many reasons, but co-payments, deductibles and paying for refraction fees are frequently a consideration.

It's easy to quote exact fees over the phone and inform callers if an insurance plan is accepted or not. We do this in my practice even if the patient doesn't ask. All you need to do is keep the fee constant for each type of exam offered. Staff members actually like the procedure of disclosing the fee in advance because it eliminates misunderstandings and confrontations in the office.


Best wishes for continued success,

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


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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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