I'd like to present a contact lens case report that I believe should be quite educational. Not a clinical case report, but a financial one. I think optometrists are severely undercharging for contact lens services and I'll use a real case from my practice to demonstrate two areas of big concern.
A clinical technician in my practice recently came to me because a patient she was working with was unhappy with our fees. The patient had a comprehensive eye exam and a contact lens evaluation. The contact lens evaluation turned into a refitting because the patient's own lenses were not performing well. New eyeglasses and contacts were ordered. After a few dispensing and follow-up visits, the contact lenses were deemed a success by both the patient and the doctor.
All the fees were charged in advance except the contact lens material fees were on hold at first because the doctor was not sure what type of lenses would be needed. Now that the lenses were finalized, my staff informed the patient of the charge for the lens products and the patient responded by saying she was not going to pay it. She reasoned that she had already paid well over $1,000 and no one had explained to her that the contacts were not included. She had been returning for a few weeks for lens exchanges and progress checks and no one said there was a balance due. My staff showed the patient an itemized summary of her fees and clearly no lenses had ever been charged, but it did not matter. To the patient it just didn't seem right.
I think the patient had a good point. We had not handled the charges very well so I decided to write off the contact lens product cost. The patient left happy. I usually let the patient win in a dispute, but I try to learn from the situation in order to prevent problems in the future. I took a deeper look at this case.
When are product fees entered?
Because we all work with free trial soft lenses and we have warranty exchange privileges with rigid gas permeable lenses, it has become quite common for doctors to delay entering a fee for the lens materials. This is especially true if we are not sure of the brand or type of contact lens we may end up with. A spherical lens could turn into a toric fitting. A multifocal lens could become monovision single vision. Brand A could become Brand B. So many doctors just charge the fitting fee and they inform the patient we will charge for the lenses when we are sure about them. Sounds good in theory but once the patient leaves your office, all kinds of confusion occurs.
In my experience, patients often don't fully understand their fees and they don't always hear everything we tell them during a visit.
I don't want to surprise patients weeks after we begin a fitting with additional charges for contact lens products.
My staff often forgets to enter contact lens charges after we get started on the fitting process. It seems there is nothing to trigger the charge.
The patient balance appears to be zero to my business office staff – and they tell patients that. Yet, it's only zero because the products have not been entered.
My solution to this problem is that we now must enter a charge for contact lens products at the time of the initial exam (assuming the patient does not want to take his contact lens Rx to go). We simply adopt the understanding that if the category of contact lens product changes in the course of fitting, which causes the lens price to change, the old contacts are credited in full and the new ones are charged. The doctor must decide what type of lens to start with and charge for it. The technician will quote a price for a yearly supply of contacts but if the patient wants a smaller quantity we will order whatever quantity is desired, but we must order at least one box for each eye. The products must be entered at the time of the fitting fee. This puts both the service and product fees on the patient's ledger and there is no confusion.
Charge the correct fitting fee
The second sad learning experience I discovered in this case audit was that we did not charge a high enough professional fee. Being the nice people that we are, we quoted a simple refit fee which is somewhat less than a new fitting. Instead of the one quick follow-up visit we anticipated, this case required four additional exams with the doctor. Of course the unexpected happens at times – but be sure you are setting the fee to accurately reflect the norm in your office.
When estimating future work that will need to be done, it's human nature to predict all will go smoothly and fees are quoted on that basis. But review a few of your contact lens records and see what really happens. Cases often do not go smoothly and I think most practices are undervaluing the cost of an office visit. As an example, if I charged $125 for the refit fee in our contact lens case, here is how I would assign the fees to the visits:
Let's assign $75 of the fee for the initial trial lens evaluation, over-refraction, counseling, and review of lens care. Keratometry or corneal topography may even be included in this fee which suggests it is on the low side.
That leaves $50 for follow up visits. Ask yourself what is your minimum office visit fee for any non-contact lens case? Should contact lens care be any less? If your minimum office visit fee is more than $50 then this fee is inadequate, and if you find that you often perform two or more visits in a refitting, then those services are definitely undervalued. In my case example with the four follow-ups, my practice averaged $12.50 per visit. I'm quite sure my chair cost is way more than that!
The point is to be fair to yourself and your practice as you decide what level of fitting work is needed. If the patient decides to not proceed with the work then so be it. That will probably not happen, but I'd rather have that then work for free or lose money on the case. Charge high enough to begin with because you can't go back and charge more later.
Best wishes for continued success,
Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week
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