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 By Neil B. Gailmard, OD, MBA, FAAO, Editor February 16, 2011 - Tip #469 
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Increasing Your Profitability with Vision Plans, Part 2


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Let's continue with our analysis of vision plans and develop a plan to make changes to your practice operations that will maximize profitability.  In this issue, I'll focus on determining which third party to bill: vision plans or medical insurance.

Routine vision or medical eye care?
Many ECPs strictly define the scope of vision plans to only pertain to routine vision care or what is sometimes called a well-vision exam.  If an examination reveals any abnormalities of a medical nature, then it is deemed to be outside the services covered by vision plans and the fees would then be billed to the patient's medical insurance.  This approach seems smart and indeed some ODs report good success with it, but it can present problems.  I advise extreme caution because patients have a bigger stake in this process than you may realize and it is possible to lose the patient and his family over it.

The difficulty is where to draw the line.  An ECP can find a medical diagnosis on the vast majority of patients, which could effectively mean that nearly all exams could be billed to medical insurance, which may pay higher fees.  It is easy to see that glaucoma patients are receiving medical eye care and require additional exams and special diagnostic tests that are not covered by vision plans.  And the healthy 20 year old, two diopter myope would easily qualify for vision plan coverage.  But what about the people in between the extremes?  Consider an asymptomatic patient who mostly just needs an update on his glasses Rx to return to 20/20 vision, but has very mild signs of allergies or very slight nuclear sclerosis.  Deciding when to call a case medical vs. vision can be difficult.

Why medical is not always better
Here are some factors that make aggressive conversion to medical insurance not in your best interest.

  • Patients may be unhappy with the decision.  In many cases, billing the exam fees to medical insurance will come back to costing the patient much more than using their vision plan.  Patients will notice this and they won't like it.  Many patients won't argue with their doctor over the billing but they will just go elsewhere next year so they can use their vision plan.  Don't collect a few more dollars for the exam fee but lose the patient forever.
  • Many patients have very high medical deductibles, so the eye exam applies to that and the patient must still pay the fee out of pocket.  The medical exam fee in some offices is quite a bit higher than routine exam fees.  This also requires you to transfer the balance to the patient and send a statement 30 to 60 days after the service.  Some patients simply won't pay it, thinking it should have been covered.
  • The refraction is typically not covered by medical plans so that must be billed to the vision plan (which does not pay well for refraction alone) or to the patient.
  • Patients typically pay some part of the premium for vision plan coverage through their place of work and they feel they did not get to fully use the benefit they are entitled to.
  • A disturbing trend is that some medical insurance plans are cutting their reimbursements so much that those fees are lower than the vision plan fees!
  • It may be difficult for optometrists to get on some medical insurance networks due to state laws, ERISA plans, or staff HMO plans.
  • Medical insurance plans may reject claims more often than vision plans, requiring more follow-up work and more write-offs.

The patient has a stake
My advice is to consider the patient's preference when it comes to billing.  If you asked the patient if he would rather have today's visit billed to his vision plan or medical insurance, what would he say?  Obviously, if additional office visits and diagnostic testing is needed, that is always billed to medical insurance.

Next week...

  • Non-covered services such as optional exam upgrades and other specialties.
  • Maximizing patient demand.  Vision plans are good at delivering patients.
  • Contact lens services - they are profitable!
  • In-office labs and reducing your cost of goods.

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.

Please Note: The views expressed in Management Tip of the Week do not necessarily reflect those of the sponsor.

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