An ethical question

[Perry Mason]

I have very little to do with the optometry. Yesterday I went for my routine eye exam, to a place recommended by a friend. After the test, the optometrist mentioned that she would like to run an additional test involving scanning/taking picture of the optical nerve. Apparently there were some slight changes but nothing to worry about. The test results were ok.

She didn't mention the test wasn't covered by the optical insurance and I ended up with a $30 copay and a medical claim as I was leaving. On a recollection, this same test had been offered to me by my prior optometrist, with a disclosure that it was an extra.

I was left with a feeling of having been taken for a ride. I wrote a review on Google but now I feel like crap since it's a friend of a friend. WWJD? Was it an honest omission on her side or a sales tactic worth of a used car dealership?

Thank you much for opinions.

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[east]

damned if you do damned if you don't.

If you truly do have a suspicious optic nerve head appearance with cupping or asymmetry, then to not further investigate the possibility of glaucoma is not following the standard of care and sets the doctor up for a nice malpractice lawsuit......... (damned if you don't)

Logically, If two different optometrists have said the same thing to you, then I tend to think you do have a glaucoma suspicion that they wanted to check with some objective test like OCT/HRT etc. ........

Now since you can't see your own optic nerve head, and don't know what a suspicious one looks like then you have to rely on the doctor looking at it. If you don't trust the doctor is doing what is in your best interest then you will reasonably question their decision for further testing, and an extra medical insurance bill, causing you to write a bad google review and post on here questions about the ethics of this optometrist........ (damned if you do)

When I go to my PCP and have blood work done because my blood pressure is a little high, and the blood work comes back roses, does that mean I was taken for a ride cause everything was normal? I still get billed. The point is that many tests are done to rule out suspicious subjective/objective clinical findings. The fact that they come back normal is irrelevant to the need for further investigation.

Now if you had an IOP of 12 OU, a central corneal thickness of 600 microns, no family history, and a cup to disc ratio of 0.3 OU. Then you got probably got taken for a ride. But I don't know that, and it sounds like you don't know if that was the case either.

 

[Perry Mason]

Thanks for taking time to respond. From what I understand there is no evidence of glaucoma, and the changes are borderline and of no concern. I was not questioning her professional opinion, however I prefer to have my options explained to me and make an informed decision. Wouldn't documenting that "the patient was offered the test and declined" take care of a potential lawsuit?

I did fee like a d*ck about the review so I retracted it and emailed the office instead.

 

[KHE]

I have very little to do with the optometry. Yesterday I went for my routine eye exam, to a place recommended by a friend. After the test, the optometrist mentioned that she would like to run an additional test involving scanning/taking picture of the optical nerve. Apparently there were some slight changes but nothing to worry about. The test results were ok.

She didn't mention the test wasn't covered by the optical insurance and I ended up with a $30 copay and a medical claim as I was leaving. On a recollection, this same test had been offered to me by my prior optometrist, with a disclosure that it was an extra.

I was left with a feeling of having been taken for a ride. I wrote a review on Google but now I feel like crap since it's a friend of a friend. WWJD? Was it an honest omission on her side or a sales tactic worth of a used car dealership?

Thank you much for opinions.

If there is a reason to be suspicious of any changes, any testing would normally be covered by your health insurance. I'm not sure why they charged you unless they didn't participate in your plan at which point they should have either informed you of the charge or given you the option to be referred to a provider to accepts your benefit plan.

 

[east]

I agree, sounds like they should have done a better job of communicating the findings and options. I find in my office poor communication accounts for the vast majority of conflict. As to writing down that the "patient refused the test"...my understanding is that this does not necessarily insulate one from losing a lawsuit. In addition who the hell wants to go through litigation even if you are in the right, and win? The time lost and headache is just not worth it.

I explain very well to the patient what I see, and why further testing is needed. If the patient refuses, then I will dismiss them from my practice with a certified letter explaining why they are being dismissed, and giving them three alternative practitioner options to go see in the area as required by my state board.

Anyway hope everything worked out for u. Glad you don't have glaucoma.

 

[east]

If there is a reason to be suspicious of any changes, any testing would normally be covered by your health insurance. I'm not sure why they charged you unless they didn't participate in your plan at which point they should have either informed you of the charge or given you the option to be referred to a provider to accepts your benefit plan.

KHE, sounds like he just had a copay on the medical portion. Very typical.

 

[PBEA]

Thanks for taking time to respond. From what I understand there is no evidence of glaucoma, and the changes are borderline and of no concern. I was not questioning her professional opinion, however I prefer to have my options explained to me and make an informed decision. Wouldn't documenting that "the patient was offered the test and declined" take care of a potential lawsuit?

I did fee like a d*ck about the review so I retracted it and emailed the office instead.

Often offices will explain their billing policy in their entrance forms. Are you sure you did not miss it? It may have included something like "all medical conditions and testing will be billed to your medical insurer and not the prepaid discount vision benefit"

As well if any patient wants to ignore possibly sight threatening conditions that is their perogative, but to expect that a doctor will just oblige them and 'play along' is another thing entirely. Some will and some won't. I don't, and I will generally move them out of my practice as quickly as possible. One reason I don't is pt communication is very dicey, as the vast majority of laypeople (including non-ophtho MD's) are totally clueless about eyeballs, etc. One only has to look at your somewhat contradictory post above as case in point. Not trying to offend but if "the changes are borderline" it sounds like a potential problem might exist (for example glaucoma), and that might indeed serve as "evidence for glaucoma", hence the desire for diagnostic testing.

 

[310]

I have very little to do with the optometry. Yesterday I went for my routine eye exam, to a place recommended by a friend. After the test, the optometrist mentioned that she would like to run an additional test involving scanning/taking picture of the optical nerve. Apparently there were some slight changes but nothing to worry about. The test results were ok.

She didn't mention the test wasn't covered by the optical insurance and I ended up with a $30 copay and a medical claim as I was leaving. On a recollection, this same test had been offered to me by my prior optometrist, with a disclosure that it was an extra.

I was left with a feeling of having been taken for a ride. I wrote a review on Google but now I feel like crap since it's a friend of a friend. WWJD? Was it an honest omission on her side or a sales tactic worth of a used car dealership?

Thank you much for opinions.

1. The optometrist likely did not take you for a ride. She was likely employed as an independent contractor and was making a clinical decision. She likely had no idea what your copay (?) would be. If she was the business owner, she should have assumed more responsibility for knowing the price.

2. The people who worked there should have been able to inform you of the price prior to the test. Not necessarily the optometrist, but someone.

 

[east]

1. The optometrist likely did not take you for a ride. She was likely employed as an independent contractor and was making a clinical decision. She likely had no idea what your copay (?) would be. If she was the business owner, she should have assumed more responsibility for knowing the price.

2. The people who worked there should have been able to inform you of the price prior to the test. Not necessarily the optometrist, but someone.

patient co-pays are generally unknown, both by patient and office. deductibles are even less known at time of service. the best the office can do is say that the test will be billed at X rate, and you (the patient) will be responsible for any deductibles and co-pays your insurance requires.

this is explicitly stated on most entrance forms (including my own) that are "read" and signed by the patient. i even have a place next to the particular part on the form explaining this where an extra initial by the patient is required just to make sure they understand it..... btw... most still dont.

it is not my job (practice owner or IC??) to know all of the 100's of insurances that i accept and all possible co-pays, and who has what left on their deductible. it is the patients responsibility.

 

[310]

^I respectfully disagree. The staff I work with is trained to fish out the problem that the above poster has had. I recommend an oct. The staff informs the patient that what it'll cost them depending on their insurance, and they either accept it or decline it. It causes lots of conflict to be avoided.

 

[wanbushui]

me too,I did fee like a d*ck about the review so I retracted it and emailed the office instead.

 

[east]

^I respectfully disagree. The staff I work with is trained to fish out the problem that the above poster has had. I recommend an oct. The staff informs the patient that what it'll cost them depending on their insurance, and they either accept it or decline it. It causes lots of conflict to be avoided.

1. I have no conflict, everything is communicated and understood by the patient.

2. It would help me greatly to know how your staff "fishes" exactly what someone will owe. How do you know what the patients deductible portion will be if say they have a $1500 deductible and just went to another provider last week who may have not billed their insurance or the claim has not been processed yet thus not applied to their deductible.

Do you then call the other practitioners office and ask how much they billed, and what their contract allows them to get paid for the particular services, then call the insurance company (and maybe get lucky enough to talk to someone who knows what they are talking about) and ask them how much the remaining deductible will be left on the patients insurance after the other office has billed them, even though the insurance has no idea what will be billed by the previous office cause they have not been received the claim yet? Maybe they take a guess.

Have you personally done the billing in your office? You end up with a lot more trouble when you tell a patient exactly what they will owe, and then it turns out they owe a different amount.

 

[east]

Mr. or Mrs. X, "The test will be billed by our office to your insurance at X rate, and you will be responsible for any deductibles and co-pays your insurance requires." .......safest way to go.

 

[KHE]

1. I have no conflict, everything is communicated and understood by the patient.

2. It would help me greatly to know how your staff "fishes" exactly what someone will owe. How do you know what the patients deductible portion will be if say they have a $1500 deductible and just went to another provider last week who may have not billed their insurance or the claim has not been processed yet thus not applied to their deductible.

Do you then call the other practitioners office and ask how much they billed, and what their contract allows them to get paid for the particular services, then call the insurance company (and maybe get lucky enough to talk to someone who knows what they are talking about) and ask them how much the remaining deductible will be left on the patients insurance after the other office has billed them, even though the insurance has no idea what will be billed by the previous office cause they have not been received the claim yet? Maybe they take a guess.

Have you personally done the billing in your office? You end up with a lot more trouble when you tell a patient exactly what they will owe, and then it turns out they owe a different amount.

Information on remaining deductibles is easily available on almost all insurance companies websites.

 

[east]

Information on remaining deductibles is easily available on almost all insurance companies websites.

you obviously didn't read my post

 

[east]

information on patient's remaining deductible on the website is not real time. i have had many situations where that number was either just plain incorrect, or, as i stated in my previous post, the deductible has not yet been applied to previous pending claims from other providers who are not up to date like we are on billing. (our local hospital is notorious for this).

I will stand behind telling the patient that you may have to pay all (give the usual and customary), some or none of what we bill for a particular test as the safest way to avoid potential problems. until we bill it and see what comes back we can never be completely sure. my opinion and experience.

 

[east]

I just printed from my EHR a list of all the insurances for which I am a provider and out came 40 pages with 16 distinct insurance companies listed per page. Kudos to you and your staff if they are finding out deductibles and co-pays on 600+ insurance companies.

By the way, many do not have websites, and the minimum wage employee at the other end of the phone representing many of these insurance companies barely knows the name of the insurance company they represent.

One question for 310 and KHE, if it is so simple and accurate to find out exactly what a patient will owe after covered services, then i'm going to assume you both collect everything up front right, no waiting for EOB etc.?

Why does every doctors office, and hospital I know of bill your insurance first, then wait for the EOB, and then bill the patient after??

 

[PBEA]

I just printed from my EHR a list of all the insurances for which I am a provider and out came 40 pages with 16 distinct insurance companies listed per page. Kudos to you and your staff if they are finding out deductibles and co-pays on 600+ insurance companies.

By the way, many do not have websites, and the minimum wage employee at the other end of the phone representing many of these insurance companies barely knows the name of the insurance company they represent.

One question for 310 and KHE, if it is so simple and accurate to find out exactly what a patient will owe after covered services, then i'm going to assume you both collect everything up front right, no waiting for EOB etc.?

Why does every doctors office, and hospital I know of bill your insurance first, then wait for the EOB, and then bill the patient after??

you are correct east, I believe they choose to try and handle things on the front end. I don't think either way is "wrong" per say and I think it's a bit ignorant of them if they are indeed attempting to cast doubt on your method.

 

[east]

you are correct east, I believe they choose to try and handle things on the front end. I don't think either way is "wrong" per say and I think it's a bit ignorant of them if they are indeed attempting to cast doubt on your method.

believe me, i would love to handle everything on the front end. collect while the patient is right in front of you (best way). we make every attempt in many cases to do just that, but their are also many instances where we have been burned by telling a patient you will owe X amount for this and Y amount for that when it comes to many medical carriers.

it's like when KHE replied to the OP at the top of this thread,

"any testing would normally be covered by your health insurance. I'm not sure why they charged you unless they didn't participate in your plan at which point they should have either informed you of the charge or given you the option to be referred to a provider to accepts your benefit plan."

No, it very well may not be covered by your health insurance, and if it is, it may not be fully covered, and even if it's "fully covered" you still may be on the hook for all, part, or none of the bill. regardless of the fact you are a participating provider. This all depends on coverage amounts, co-pays, co-insurance, deductibles, ERISA directed, COBRA directed, etc.

 

[310]

believe me, i would love to handle everything on the front end. collect while the patient is right in front of you (best way). we make every attempt in many cases to do just that, but their are also many instances where we have been burned by telling a patient you will owe X amount for this and Y amount for that when it comes to many medical carriers.

it's like when KHE replied to the OP at the top of this thread,

"any testing would normally be covered by your health insurance. I'm not sure why they charged you unless they didn't participate in your plan at which point they should have either informed you of the charge or given you the option to be referred to a provider to accepts your benefit plan."

No, it very well may not be covered by your health insurance, and if it is, it may not be fully covered, and even if it's "fully covered" you still may be on the hook for all, part, or none of the bill. regardless of the fact you are a participating provider. This all depends on coverage amounts, co-pays, co-insurance, deductibles, ERISA directed, COBRA directed, etc.

The large majority of my patients are either on Medicare or Medicaid-linked health plans which do not have copays for tacking an oct onto the end of an exam. It's a short list that requires a copay for the OCT so it probably isn't as complicated as your situation.

 

[KHE]

I'm not really sure why this is such a massive issue. We don't really have too much trouble. No, we do not collect at the time of service if patients have deductibles. But we view online what the remaining deductible is and we tell them that they have an unmet deductible so it will probably be around $xxx.xx dollars. We know pretty closely what the contracted rate is for the plans in our area so there aren't normally any big surprises.

You said that you have 40 pages and 16 different companies listed per page. We do not have 640 different plans that we are contracted with. I've never heard of such a situation nor have I run into ERISA or COBRA issues that you seem to have. If I had 640 different insurance companies to deal with I'd put a shotgun in my mouth.

 

[PBEA]

I'm not really sure why this is such a massive issue. We don't really have too much trouble. No, we do not collect at the time of service if patients have deductibles. But we view online what the remaining deductible is and we tell them that they have an unmet deductible so it will probably be around $xxx.xx dollars. We know pretty closely what the contracted rate is for the plans in our area so there aren't normally any big surprises.

You said that you have 40 pages and 16 different companies listed per page. We do not have 640 different plans that we are contracted with. I've never heard of such a situation nor have I run into ERISA or COBRA issues that you seem to have. If I had 640 different insurance companies to deal with I'd put a shotgun in my mouth.

not a "massive issue", but your confusion is manifesting in a way that is misleading. You don't know why the guy can't give an exact number for a billing question, yet you acknowledge that there are various co-pays, deductibles, co-insurance that make giving that difficult if not impossible in some cases. You yourself don't collect at the TOS.........

You claim you don't take all "those plans" yet you are a provider for most major medical insurer's (I presume). Each of which has a virtually infinite number of different policies, different coverage, different copays/deductibles, etc.....

How could you possibly be confused about the pt having to pay a copay?

 

[east]

it's not a massive issue, i just looked at this thread as an opportunity to give my opinion to those ODs starting out. obviously our practices and situations are different. my main point is that the OP (in my opinion)

A) was not likely "taken for a ride" and
B) should not expect to be told exactly what he/she will owe for every procedure or test prescribed.

it remains my experience for anyone who cares, that it is dicey to quote patient balances with medical insurance prior to receiving an EOB. i would recommend against it, as it can cause even more confusion. when you tell a patient their bill will be about/approximately X, all they hear is X, they tend to forget the about or approximately part. this leads to trouble.

i guess w'ell have to agree to disagree, but for those of you establishing practices, these are issues and policies you will have to consider and establish. whichever way you choose to handle this, you must remain consistent.

 

[20DOC20]

The optomap is a wonderful test -- helping the optometrist not only diagnose retinal diseases but also document future changes to the retina.

Most optometrists lease the equipment. It costs around 5K just to get the equipment in the door to open the lease. The optomap company charges the remainder of the lease per photo at a wholesale rate of around $15.00 per patient. That's the price just to view a pair of full-size retinal photos.

You got charged just $30.00 for the test? That's fair. More than fair, actually. Considering the 5K down, the OD may not even be making a profit. I'd charge at least $45 for the first optomap and then $30.00 for follow-up optomaps (they should be retaken at every exam to compare photos).

As a private contractor, working for another optometrist as fill-in, we are sometimes kept in the dark about prices. I try to inform the patient about anything that deviates from the standard exam price beforehand if I'm made aware of prices by the OD who has hired me.

I get really irritated when the work of our hands is valued so little by the public. Patients always assume their doctor is rich and is cheating them, when actually, I've personally not had any personal health insurance for myself or employees the past 3 years just to keep the doors of my practice open. (Thank VSP, Eyemed and Davis Vision insurances for that).

Patients really don't care about their eye health. They just want their numbers. The attitude of the public makes me want to quit the profession and go into a more valued occupation such as cosmetology.

Really, would you rather spend $30.00 on a quality retinal photo or on dinner for two at Sizzlers? I'd guess the latter.