How to deal with ophthalmologist refracting under public health care

[Dr Colin K Chan]

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Hi,
I'm from Toronto, Ontario. As an optometrist, we bill the government (OHIP) for certain conditions. But for routine eye exams for anyone between 20 to 64 yrs of age, they are not OHIP covered. Problem is, there is an ophthalmologist in my area who refracts (most ophthos don't anymore although they still can if they choose) and bills OHIP for everyone. Technically, I guess everyone has trace NS or extremely mild bleph or has something minor to bill. But in reality, the standard of practice is charging the patients, not OHIP, unless these conditions are "significant". Since he bills OHIP for everyone, people think everyone should get free eye exams and they think optometrists are ripping them when we tell them their exams or not covered.
My question is, what can I do about it or is there even anything I can do? Any insight would be appreciated. Thanks a lot.

 

[Shnurek]

Start doing what he/she is doing. Ophthos in America do the same thing. Bill medical first no matter the chief complaint and then switch to vision later if nothing medically significant comes up. Our government estimates 10% of medicare money is lost to fraud. Also, you can talk to him/her or you may be able to report him/her. Become a patient of theirs and record the interaction or something of this sort. And/or bring it to the attention of the media. Lots of things you can potentially do. I'm sure more experienced individuals can jump in on your question.

 

[q1we3]

That is odd because in most parts of Canada it is virtually impossible to get an appointment with OMD (because of the shortage) without referral from a optometrist or family doctor and it has to be a serious condition. He became OMD to do refractions? But I doubt you can do much. Best thing would be let other ODs know around the area, how he/she is making you all look bad so they won't sent any referrals.

 

[Tippytoe]

Not much you can do in reality. You could report him to try to provoke an audit. But just know this will cause a great amount of ill-will and payback can be a bi-otch.

We have had problems with pediatricians doing a vision screening and then biling a full eye exam, thus using up the patient's insurance exam benefit. In this case we got the patients involved and they raised hell until it was stopped. There is fraud everywhere. Of course it's going to be hard to get your patients involved when they are getting a free eye exam. Good luck.

BTW, I've never heard of an general ophthalmologist practice that did not refract (a tech refracting that is). How, exactly, are they supposed to know what the patient's best corrected visual acuity is without refracting. It is the 'vital sign' of the eye?

 

[Visionary]

Here's my experience, as one of those evil ophthalmologists in the US. Here, we don't actually get paid for the refraction service by medical plans, only by the eye plans. If billing medical, refraction ends up being a separate, out-of-pocket service. If the patient comes in for a medical complaint, we bill medical, even if they have an eye plan. If the patient has no complaints, we bill the eye plan. Most patients want the lower co-pay, which is the eye plan, but if they really have a medical issue that needs management, we must bill medical to cover the ancillary testing, etc. Many patients will actually make their medical and eye visits separate, because of the co-pay difference and the separate refraction fee under medical. I have patients who see me for medical (retina) management and still see their optometrist or general ophthalmologist for refractions. Others prefer to see me for both. It's up to them. I don't doubt that some docs in both camps abuse the system as you describe, though. Of course, that means, at least in the US, that those patients must pay a higher co-pay plus a refraction fee. Most patients will scoff at that, if they don't have a legitimate medical complaint. With a socialized system, like Canada's, don't know how that works.

 

[mclem222]

I think the sting operation stuff is stupid. You better be dotting your I's and crossing your T's because payback is a bitch I don't think you want to start that type of war with an OMD

 

[Tippytoe]

Here's my experience, as one of those evil ophthalmologists in the US. Here, we don't actually get paid for the refraction service by medical plans, only by the eye plans. QUOTE]

Just for the record, there are a few medical plans that do pay for refraction. It varys by region of course. Here BCBS pays (well) for refraction (92015) in addition to the exam. Most, like you say, don't or just bundle it together.....and of course there are vision plans that bundle the refraction with the exam (our friends at VSP).

For the benefit of students that are probably wonder why in the hell is a refraction separate from the eye exam............Medicare made it that way. A comprehensive eye exam, according to Medicare covers certain elements of the eye exam (acuity, EOMs, IOP, VF, etc...) but refraction, strangely, is not one of the elements.

Insurance is basically a foreign language in which there are very few understood rules. And I'm sure the insurance companies like it that way. You can call 4 times and get 4 different answers. They have very little accountability.

 

[Visionary]

Just for the record, there are a few medical plans that do pay for refraction. It varys by region of course. Here BCBS pays (well) for refraction (92015) in addition to the exam. Most, like you say, don't or just bundle it together.....and of course there are vision plans that bundle the refraction with the exam (our friends at VSP).

For the benefit of students that are probably wonder why in the hell is a refraction separate from the eye exam............Medicare made it that way. A comprehensive eye exam, according to Medicare covers certain elements of the eye exam (acuity, EOMs, IOP, VF, etc...) but refraction, strangely, is not one of the elements.

Insurance is basically a foreign language in which there are very few understood rules. And I'm sure the insurance companies like it that way. You can call 4 times and get 4 different answers. They have very little accountability.

Good clarification. Yes, in my area, only eye plans cover refraction. We charge a separate $30 fee, which is actually far below what most charge. I've heard as high as $75, which seems ridiculous.

 

[Shnurek]

Sounds interesting. Bill medical plans and then have a $30 refraction cash charge. As per KHE, he stated he lost thousands of dollars just trying to track down payments from insurance plans so the more straight cash you implement the better as I keep hearing from almost everyone. Cut out the third party. In what states do ODs do cosmetic procedures such as Botulinum toxin injections?

 

[Tippytoe]

Sounds interesting. Bill medical plans and then have a $30 refraction cash charge. As per KHE, he stated he lost thousands of dollars just trying to track down payments from insurance plans so the more straight cash you implement the better as I keep hearing from almost everyone. Cut out the third party. In what states do ODs do cosmetic procedures such as Botulinum toxin injections?

No states allow ODs to do Botox or any other cosmetic procedure (other than a colored contact lens). Forget about that fantasy.

As far as refraction, when you think about it, it probably should be a $75 charge but I doubt anyone would pay that. It IS what makes people see after all and what we base their glasses and contact lenses on. I get away with a $40 refraction fee but that doesn't stop the old people from whining since they think everything should be free just because they were lucky enough to live into old age.

There are VERY few cash procedures in optometry anymore. Some people sucker patients out of money for ortho-k/CRT contacts. And some sucker them out of cash for vision therapy since no insurance covers that. But for the most part, 95% of what we do is insurance now. So half of your working life will be spent on hold with an insurance company unless you hire someone specifically to do that.

And then you have the trick of trying to explain to a patient why their $15 copay vision insurance doesn't cover their glaucoma/cataract/macular degeneration exam which is an $80 medical copay. They love that.

Most MDs only have medical insurance to worry about. ODs and OMDs have both. Dentists are super smart. They have hardly any insurance to worry about (not to mention no competition). That's why I recommend dentistry to young people.

 

[thiaeyemd]

My cousins all live in England where there is national health care which doesn't cover dental stuff (all out of pocket) ..the saying there is that every dentist has a porsche.

 

[Visionary]

And then you have the trick of trying to explain to a patient why their $15 copay vision insurance doesn't cover their glaucoma/cataract/macular degeneration exam which is an $80 medical copay. They love that.

So true.

 

[Dr Colin K Chan]

thanks. to clarify when u said it's hard to get an appt with an OMD, generally true. but the ones that i'm talking about, either the lazy ones or the old guys that don't want to deal with pathologies anymore, they just sit and refract all day (they don't even look inside the eyes), spit out the prescription, and bill as full eye exam. obviously, no ODs would refer to them. however, opticals love referring to them. quick turnover and they all bring their script back to the store.