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TomOD

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Emily_f,

What are some of the problems OD's face you ask!

Well that probably depends on who you ask. In my opinion, the biggest issue OD's face is with themselves. There seems to be a huge inferiority complex within the profession. We are are worst ememy sometimes. We have a bunch of OD's working in commercial establishement and then wondering why others don't always give us the "respect" we think we deserve. (Hello.....you working at Walmart!!!)

Most OD's don't charge nearly as much as we should. I see advertisments all the time for $39 eye exam. Now what other type of Dr. are you going to go to for $39...probably not many (if any).

P.S. Medicare reimbersement is $114 for a comprehensive exam and $69 for an intermediate exam (OD or OMD). If Medicare thinks OD's exams are worth that much, shouldn't OD's???

Managed care is not really that difficult to deal with. It affects optometry as well as every other health care field. I had a pt. (and his family) yesterday who was a cardiologist. His wife had to become his office manager just so she could get a handle of the insurance. Every employee he had messed it up. BUT if you learn the game, it's not that hard.

Competition may be an issue depending on where you are. I have alot of eye docs around me, both OD's and OMD's. But if you do a good job and people like you, you will have plenty of patients.

Optometry is a great profession......I LOVE it.

Tom, OD
 

emily_f

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In what ways is managed care an issue? Is it because you don't get reibursed for certain services and there is more paperwork? Sorry, I don't know a lot about it

Thank you,

Emily
 

christie

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Hi Emily,

I think managed care is an issue Optometry faces, and of course many other health professions. I know this personally, b/c I am an office manager for an Optometrist, and when I interviewed recently at one of the schools - an admission committee member mentioned that managed care is an issue Optometry faces.

Basically, insurance companies don't want to pay the Optometrist what they should, whether it be a dilation, visual field or a comprehensive eye exam, even though the diagnoses are appropriate. It can be frustrating sometimes, battling with these insurance companies..but it has to be done.
 

Jubileee

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Think of managed care companies as wholesale companies. When you go to Sam's Club or Costco, you get items cheap cause it is in bulk. The managed care companies negotiate a lower fee for their patients, either paid by patient or said insurer, and in return you are supposed to make up for the difference in the volume of patients you see.

For example when I used to be an office manager in Seattle, the going rate for an exam was $65. Blue Cross Blue Shield (BCBS) only paid us $40. That is $25 less than what a cash paying patient would pay. Then again, both Microsoft and Boeing employees had this insurance carrier. And these two companies were two of the largest area employers. So therefore by accepting the BCBS insurance, we were able to capture a large precentage of those potential patients. (cause we all want to go where our insurance will pay if at all possible to save on our out of pocket cost.)

On materials it is a different story. Some plans just give a set dollar amount. And the patient can spend it any way they chose between glasses and contacts. Some plans pay based upon the type of lens. Again using the BCBS plan, you have a patient who has presbyopia, and is trying to decide what way they want to correct their vision. You can do single vision readers, the cost of the lenses (minus frame) is about $90. Lined bifocals are $130. Progressives and Trifocals are $189. Now BCBS will only reimburse you for $45 on SV, $65 lined, and $95 for progressives and trifocals. The remaining balance for the basic lenses is discounted out. So to make any real money on them you need to either A)sell them an expensive frame or B) get them to splurge on premium lenses such as polycarbonate or hi-index materials, or coatings such as A-R. Then I guess there is C) getting to buy a second pair for fun or Sun..

For Frames BCBS would pay $40 on the first $85 of said frame and then the remaining balance would have a 20% discount applied.

The trouble some people run into is that they do so many managed care plans or maybe I should say the wrong managed care plans that they can barely make a profit. Especially if they don't promote the premium lenses and multiple pair mentality.

There are some docs who will have to do 30 exams a day in order to break even cause they are getting such low fees in return from the managed care companies. I know of a few that would only pay $25 per exam. That isn't even enough to pay off your overhead let alone any other associates and have something for yourself...

Cassandra
 

TomOD

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Yea, again, Managed care (ie. insurance) affect ALL health profession, MD's, dentists, chiropractors, podiatrists, psychologist etc. But managed care is not necessarily a bad thing. In fact it probably causes many people to get an exam that they wouldn't have otherwise. Some plans pay well, some don't. Some doctors are stupid enough to think that a plan that they sign up for that is going to pay them $40 for an exam while promising to get them 100,000,000 patients (and while your chair-cost is $45). But what they don't realize is that if you lose money on every exam it doesn't matter how many of those exams you do.....you will lose alot of money. Seems simple, but you would be amazed at how many doctors don't get it.

Anyway, I am probably getting off track here. Managed care is here to stay and it is sometimes a headache (mostly because the pt. thinks everything in the world is covered for them). If you learn to work with it instead of against it.....it ain't bad. If OD's only accepted the good plans and refused to accept the bad ones (VSP), these bad plans would not exist. Unfortunately there is always 1 or 2 doctors who think they will "underbid" everyone and get all the patients.........doesn't work. They just end up working their buttocks off and just break even. Doctors, in general, are poor business people.

Tom, OD
 

cpw

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I thought VSP was one of the "good" ones, Tom.. from what I've heard they pay more per exam than most other plans.. but I'm not sure how much. I think it varies by region.

How much does VSP pay per exam where you are? (just curious) you don't have to tell me if you don't want.. and if you do have concerns/problems with them could ya fill me in on what they are. I know they are the HUGEST carrier I've ever seen for vision.. so it would be nice to get an inside on what it's like to work with them. I already know their audits are HELL! I've been there through two of 'em.
 

TomOD

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I don't know exactly what VSP pays for an exam because I don't take it. I did work briefly at a place that did take it and have heard from others what a mess it is on the materials side (glasses). The pt.s don't know what is covered, you don't know what is covered, and when you call them, they can't really tell you what is covered. There is about a million different "plans within a plan".

Cassandra, You guys are expensive on those lenses. Here we charge $59 for SV, $90 for ST-BF and $166 for progressive.....Maybe I should raise my prices...Hmmmmmm. But then again, most of our sales are cash so I guess $59 cash is equivalent to $100 on insurance (which equals $30 a month down the road).
 

christie

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We take VSP at our office, and it doesn't seem so bad. Basically, you have to call VSP to find out if a patient is eligible for exam, frame and lenses - the voice recording tells you what plan number they have and the authorization number.

Then you look in the VSP book, and find the patient's plan number, and the book tells you their copay, frame allowance, and cl allowance.
 

Jubileee

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VSP isn't all that bad. Of course where I work at we don't accept it cause they require all their glasses to be manufactured at their lab using their materials. (Or at least they did about 4 years ago)

Some VSP plans allow you to go out of network, some don't. Most of their pricing in based upon Wholesale value for materials. For example they will pay for certain frames up to a $40 wholesale value. Depending on the quality of said frame and the markup the dispensary has, this could equal the cash equivilant of a $120 frame..

Lenses are based upon a wholesale value as well.

I can't remember the specific numbers (both my man and myself have had VSP insurance before) but I do remember reviewing the plan and and realizing that you got more benefit out of it when you went out of network and got a 20% discount at Lenscrafters (they will routinely do this if they don't carry your plan) and then submitting on your own for reimbursement from VSP.

The funny thing is that alot of these vision plans also rip off the patient. There are many that charge you more money over the plan year than what they'll pay out or discount out for exams and glasses or contacts...

I know some that charge $10 a month and will only pay for an exam and glasses every two years. And then the maximum amount paid towards glasses or contacts was $150.

On the other hand I know some people who bought really cheap "discount plans" that end up saving 50% on every pair, and it is valid for unlimited pairs...

I do have to agree with Tom though that since the amount of Vision care plans has grown, more people are taking advantage fo getting regular eye exams and updating their prescriptions. You just have to becareful of what plans you accept.

Cassandra

(Tom, the funny thing is in the Seattle area, our prices were amongst the lowest. Then again, the competition in our area specialized in custom 3 piece mounts, or designer frames such as Cartier. We used toe have people go to one specific competitor that used the facial analysis and viewing systems, decide on a shape or even sometimes a specific frame, and come to us to save a $100-150. In the Indianapolis Market, we are middle of the road. Though right now we don't sell regualr CR-39 anymore. Our basic lens now is the "Duralens" which is the Sola Ultra Tough lenses with UV. So it does have a better scratch resistant coating on it. )
 

Ballew21

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Hey Cassandra, :oops: ). Congrats on the Chile trip. Do you know if anyone else from the region going?

Managed care, what a fun topic. (As Cassandra knows, I am the unfortunate soul who is the insurance supervisor so I know most insurance plans backwards and forwards and it is the aspect of my job that I hate the MOST. Especially after the day I had today, *ugh*.) My biggest gripe is that most patients have NO idea who is their vision care provider is (let alone if they have vision benefits at all), which makes everything all the more difficult. Personally, I think that it is almost impossible for a doctor to avoid taking any managed care plans b/c most doctors would usually sacrafice some revenue in fees to entice patients to visit the office. It has become a necessary evil in all types of medicine, and as a doctor, you have to choose and pick which plans are more "profitable" than others.

It's funny that we're having all of this talk about VSP because I read in Optometric Management about a year ago that VSP (Davis Vision too, I think) was started by a group of private OD's because they were fearful of the influx of commercial practices.

BTW ... TomOD, have you run into any difficulty in receiving reimbursement from Medicare on an eye exam? I haven't run into any problems with cataract post-operative care, but the office in another part of Indy has been a Medicare provider this year, but they have had a horrible time getting reimbursement and are scrapping the plan at the end of the year.

Nick
 

Jubileee

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Hey there Nick!! I know two others who are going on Missions this year. Gloria from the Carmel store, and Chris from a Seattle store.

You are correct. VSP was started by a group of private docs who wanted to protect themselves from commercial opt and managed care. They used to (not sure if they still do) require using their own materials, and the glasses must be processed at their own lab. This way they can control the costs to the best of their ability.

This is the primary reason why a lot of commercial establishments don't accept the plan. Take for example where we work at. What would the point be in sending glasses to be made at a VSP lab when we have everything to make them in our store. Especially since our quick turn around is a motiviating factor for most people who come in the door.

I have also seen some of the quality that has come out. The frame materials they used to use were somewhat to be desired (think prison labor work) and cosmetics were bit shabby. Yet that was a few out of the thousands I know they do a month.. and hey there have been some glasses I am ashamed ever came out of one of our labs :rolleyes: .

Cassandra

PS What is it now Nick, one more week and then you can have some temporary sanity ;) You need to make sure you have time for a life admist all that work and school...
 

TomOD

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Nick,

I LOVE Medicare. I would have an ALL-MEDICARE practice if I could. They pay great ($116 in 2002 for a comprehesive eye exam). They pay for fundus photos ($57), anterior segment photos ($52), Visual fields ($48), Epilation ($87), Punctal plugs ($178), Dilation and Irrigation ($154) etc. All with medical justification of course. Most private insurance companies don't even come close to Medicare.

And they don't cover eyeglasses (except after cataract surgery). The patient pays cash for them. You just have to make sure you have some pretty big, ugly horn-rimmed granny glasses on hand.

And, I have found that older patients are much more loyal, and respectful than money-pinching, whining, younger people.

We have a 98% reimbersement rate for Medicare. They are my bread and butter. (AND I like the ocular disease........and they provide me plenty of it).

P.S. There was a discussion on the <a href="http://www.webcom.com/optcom" target="_blank">www.webcom.com/optcom</a> list a while back about VSP. Many doctors are dropping it as fast as they can. VSP is nagging doctors and making them jump through all kinds of hoops with audits and surveys that they are required to fill out and, of course are not reimbersed for their or their staffs time. It just makes it tough when an insurance plan tells the patients what your wholesale cost it. It's none of their business.

That's why I don't do VSP.
 

TomOD

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Oh yea,

I don't do (file) the Post-Op Medicare glasses. Medicare don't pay for these like they are supposed to. These claims go to a different department...... to DME (durable medical equipment). They are idiots....at least the ones I have dealt with.

My post-op cat. pts. usually buy their own glasses. If they don't want to, I give them an rx and tell them good luck. I think there a few place around that do them.
 

UWSO2003

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Hey Tom,

I still can't believe how well OD's get paid down where you are ... it's just unbelievable. I doubt you would even spare a second of though to working in Ontario!

OHIP (Government funded health care) pays $39.99 for a full OVA, and I think $19 dollars for a partial OVA.

Photodocumentation isn't covered, so it's hard to convince pt's to get it ... they're used to having everything paid for by the gov.

I would die right now if OD's could get the gov, or even patients to pay $48 dollars for a VF. As it stands, most OD's just swollow the cost of the HFA. Some skrit around this issue by bringing the patient back another day, thereby getting a whopping $19 dollars.

There are rumblings of eye care being deinsured for 19-64 year olds. This has happened in several other Canadian provinces, and has seen the OD's salary rise. Can you imagine .... some new graduates here make the same amount as a high school teacher in New York state (no offense ... but why did I go through all this extra traning to be an eyedoc?).

Ah well ... enough moping. I have a brutal Peds exam on Monday :( .
 

Ballew21

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Cassandra - My last final is next Saturday morning, *cringe*, so after that, I'll have three weeks of relative peace and quiet until classes start in January. BTW, If I knew how to PM you, I would tell you about my schedule next semester since we'll have at least one class together, I think. I'm taking Anatomy, Western Civ., Psychological Statistics, and Chemistry (I'm taking C106 since they didn't give me credit for it when I transferred it in from Carolina, which is screwed up b/c they gave me credit for C105/C125 & C110 even though I took an honors class which combined C105 & 106 into 1 term and C341 & C343 into another term.)

TomOD - That's incredible, 98% reimbursement rate. I have a few hundred claims at the Lafayette office that I would be more than happy to send your way. *grin* I had to teach the techs up there how to file claims, they didn't listen, and all heck has broken loose up there. Over 5-digit figures for balance dues is not great for an office less than a year old. *smirk*

BTW, I read somewhere that if you file for an examination more than once, that you have to use a different diagnosis code each time that you file for an exam or else you would be issued a denial. I thought that was kind of wierd, so I wanted to ask you about it.

Thanks,
Nick
 

TomOD

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I am lucky to have an outstanding insurance clerk (who is also my wife). She MAKES SURE we get paid because she has a vested interest in the business. You really have to stay on their butts because they will "reject-at ramdom" if you let them. We just got a Medicare denied claim for a comprehensive exam (92004) for a oculocutanous albino. They paid me for fundus photos and anterior segment photos (because she had corneal dystrophy) but did not pay for the actually comp. exam saying it was not a "medical necessesity". Our main diagnosis was oculocutaneous albinism.....which is not really "eye-specific". We will refile it with retinal degeneration (which is actually a result of the albinism) but the idiots at MCR are too stupid to figure it out. They only know codes. But we will get paid.

What was the other question......Oh yea

Nick,

You can file as many exam as are justifable. If a pt. comes in with a corneal ulcer. The first visit would be a comprehensive (92004). I would treat them and probably see them back in a day or two. This visit would be a medical eye code (99213 Level 3 code). If it hasn't resolved, I would see them back again and code it as a level 3 or perhaps 2 (92012).

What you may be thinking about is filing more than once comprehensive exam. A comprehensive ophthalogical exam is defined as one that includes a diagnosis and treatment of a new condition. You can not see someone back every 3 -4 months for a cataract check and bill a comprehensive. You can see them back if they think it is necessary (ie. in the case of poss. pupillary block causing increased IOP's) and bill a medical code (a 99_ _ _).

If you see a new pt. with a cataract and bill a comprehensive exam and the pt.s comes back in 1 week with a retinal detachment (or any other differnt diagnosis) you can bill another comprehensive exam.
 
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