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 By Neil B. Gailmard, OD, MBA, FAAO, Editor June 2, 2010 - Tip #433 
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Managing Patients Who Want It for Free


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I received an interesting email from a reader who asks about a very real situation that I'm sure we all run into in our practices. Here is the email:

"In the age of no responsibility or accountability that we live in, how do you handle those situations where patients don't feel they have to pay for services rendered? Particularly those contact lens patients whose prescriptions have been finalized and return one, two, or three months later with issues they want resolved. Is there a charge for these appointments? How do you handle this? This has been a recurrent theme and has the staff continually on edge and in a defensive posture. Do you bill their medical insurance if there is a relevant issue on a medical level? I know you espouse a heightened level of customer service, but there is a point to let a patient take their issues elsewhere where they get services for 'free?' How do you handle this whole arena? I would appreciate your insights to aid us in handling these situations which are very recurrent."

From the patient's point of view
Before I give any advice on how to manage these sticky situations, let's first try to understand them better. The reader has presented us with a good understanding from the doctor's point of view but it is always helpful to see these things from the patient's point of view as well. Why would these patients expect the visit to be free? We know these patients have "issues they want resolved" but another way to phrase that is they have a complaint about a product they purchased. I'm not saying an error was made in the prescription of the lens and I'm not assigning blame, but from the patient's point of view, the contact lens he recently bought is not working right.

In my practice, we would describe this type of visit as "CL Trouble." This office visit goes by many other names in our profession, such as Rx trouble (if it were about eyeglasses), Rx problem, grief case, Rx complaint, trouble-shoot, Rx remake visit, Rx re-do, Rx recheck, etc. It doesn't really matter what we call it as long as we are talking about the same thing. Of course, the reader may be referring to some variation of this and I may be oversimplifying, but let's begin here.

To me, it makes no difference if a complaint is about contact lenses or eyeglasses. In either case, the patient is dissatisfied with a product I prescribed. I also don't know the reason for the dissatisfaction yet or whose fault it was. I'll determine that when I examine the patient.

Was the problem there from day one?
I think the answer to the question above is primary as we try to assess if it's fair to charge the patient for additional professional care.

If the patient alleges that the problem (discomfort, blurred vision, redness of the eye, etc.) was always present with a new product, I would generally see them for an office visit at no charge. Yes, the patient could be dishonest with his answer in order to gain sympathy, but I will probably discover clues to that as I go along and it is really a separate issue anyway.

Of course, the time period from the date of dispensing is also important. Our reader's email gives an example of one, two or three months later. More on this in the next section.

I know there is a school of thought that all care by the eye care practitioner (ECP) should have a fee associated with it, even if it is a follow-up to a complaint, but that approach is a bad idea if you are trying to build a practice. Our society and marketplace simply won't accept that because the ECP is also profiting from the sale of the product. That is one key difference between an ECP prescribing glasses or contacts and a general physician prescribing a drug.

What took you so long to tell me?
When I'm seeing a patient with CL trouble or (Rx trouble) and the time period from the date of dispensing is beyond reasonable, I find that asking the question above makes a huge difference. Try it and you'll see what I mean. I can't tell you exactly what to do in every circumstance, but when you hear the patient's answer, you'll know. If the patient gives you a surprising answer, like "I've been out of the country and just got back" or "My wife was told she has cancer and everything else had to wait," you will be more understanding. If there is not a great answer, the patient usually says "Yeah, I know I should have called you sooner but I thought it might go away." In the latter case, however, at least you communicated to the patient that he has some responsibility to let you know of a problem in a timely fashion. If you decide to help the patient at no charge, at least you get some good will credit for being very understanding.

If the patient's answer is "Well, it didn't start bothering me until last week" and the contacts were dispensed four months ago, you may be justified in charging an office visit fee. Continue to examine the patient and find the cause of the trouble and you'll know what to do. You might even consider asking the patient what he thinks would be fair regarding the fee.

Tell patients in advance
This point is vital in so many aspects of patient satisfaction issues. Consider how the following could help prevent a sticky situation.

  • The doctor or a clinical technician could have told the patient at the time of the fitting that follow-up visits are not included in this service (to keep costs low) so if you have any problems with these new contacts be sure to call us right away.
  • The receptionist could tell patients over the phone that there may be an office visit fee. Train your staff to look at the date of dispensing while taking the call to schedule an appointment. If your policy is to see complaint visits within 30 days and it is beyond that, the receptionist should say so. You may still make an exception based on the circumstances, but the time to bring up the possibility of a fee is over the phone. Doing this prevents confrontations at the front desk after the visit.

Charge higher fees and include follow-up care
Since the need for follow-up care is recurring frequently for our reader, I would raise the contact lens professional fee so follow-up visits can be included if needed. I presume the ECP is trying to be a nice guy and keep the initial patient fee low when he believes the contact lens fit is final, but since that is often not the case, I would raise the fee and require a follow-up visit. Or raise the fee and make follow-up care optional.

I made the point just two weeks ago in tip # 431, but I'll repeat it here. Great customer service is very hard to deliver when the fee schedule is value oriented. Raise your fees in general and you'll find it is much easier to let patients win these scenarios. If vision plans are very dominant in your practice, raise the fees anyway.

Medical insurance
To answer the reader's question about medical insurance, I would make such billing secondary. I would decide about a fee first, as if the patient was going to pay. I like to presume that the patient has a $2,500 deductible (and many do). I will bill medical insurance if there is a fee for the visit and there is a medical diagnosis. A good test for billing medical insurance is if the patient wants you to or not.


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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