- Joined
- Jun 28, 2006
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There have been many recent posts lamenting the state of our profession with continuing downward pressures on reimbursement from 3rd party payors (CMS and insurance companies particularly on cataract surgery) while the costs of doing business are increasing (more regulation, more expensive supplies/technologies, higher salary demands, inflation, etc).
I have always found it remarkable how resilient and entrepreneurial our specialty has been over the years. We're fortunate to be able to significantly improve the quality of our patients lives and have patients who value our expertise and service even when CMS does not necessarily do so with their fee schedules. I don't think what we're discussing here needs to be a secret. The more we normalize these types of activities, the better it will be for all of us. What are you guys doing to combat decreasing reimbursement and increased expenses? Are you offering new services that you previously/traditionally would not? Are you charging for things that you did not previously for? How useful/big of an impact are these measures? Has there been patient blowback? Does it feel ethical to you? I'll start.
Refractive surgery fees
1. Astigmatism and presbyopia correction concurrent with cataract surgery. Medicare currently pays around $540 per cataract surgery which has been continually decreasing over the past few decades. It is now at a point where many surgeons choose to not do or only do them as a loss leader for selling patients refractive services. CMS has ruled since 2005 that astigmatism and presbyopia correction are not covered by medicare and thus are billable to the patient. Fees charged can include surgeon/professional fees, lens costs, femtosecond lasers if used, intraoperative biometry, refractive guarantees, eyedrops, lipiflow/amniotic membrane/ocular surface treatments. Many doctors have expressed that they feel like "used-car salesmen" trying to sell these services. I personally provide some of these services and think many of them are worthwhile. It's remarkable to me how much patients are willing to pay for these services and unlike 3rd party payments, I've seen these prices continuing to increase. How much are these fees in your markets?
2. Eyedrops, lipiflow/amniotic membrane/ocular surface treatments. Some of these feel like "snake oil" to me. A lot of doctors are paid big money to promote these activities. I do not do these things on a routine basis.
3. Femtosecond laser/biometry and other out of pocket stuff. I can do great surgery without them but they are effective in many situations and can significantly increase revenue.
4. Comanagement fees. These are actually paid out to other doctors to take care of the patient pre/postop. Sometimes they can include "refractive comanagement" where the other doctor gets paid above and beyond what they can bill medicare/insurance. These can feel dirty to me but in the big cities, you sometimes have to pay to play (if you want these patients which can be lucrative). Ironically, one of my colleagues referred their patient out to do a complex LASIK treatment and he unexpectedly got a comanagement check in the mail to take care of the postop. Sweet.
Afterhours work
1. Hospital call. Traditionally nobody got paid to take call at the local hospital and you would build your practice this way. I've participated in some locales where the doctors that took call got paid a substantial amount of money and other locales where they were payed zip. This sometimes depends on local regulations. Some hospitals require you to take call if you want to use their ORs. Some insurance companies require you to have hospital privileges and the hospitals can subsequently require you to take call even if you don't operate there. I've heard as high at 14,000 per week. The hospitals where I practice don't pay and so I currently do not take call. It would take something in the neighborhood of what was described above for me to even consider it.
2. Practice call. We currently have physicians on call for our practice. Every practice I've ever worked at takes patients phone calls after hours for emergencies (many of them are not emergencies). Why do we still do it (for free)? I know tons of direct primary care / concierge practices that charge their patients an annual fee for priority scheduling, possible weekend visits, being able to text/call their docs after hours. Thoughts about charging a concierge fee to allow after hours calls/exams??
3. Patient calls. Patients will sometimes call during office hours. Not all questions require an in person exam. Thoughts about turning all patient medical calls to telehealth/telephone exams?? Lawyers charge by the hour. There's a mechanism for us, why can't/don't we?
Random fees
1. Refraction. Medical insurance generally does not pay for refractions. Vision insurance will sometimes pay for refractions. Vision insurance pays like $25 for an exam? We don't take vision insurance, we never will. May medicare never "cover" refractions.
2. Fundus photos. I know tons of optometrists who recommend fundus photos for all their patients as a cash pay service. I was "taught" the practice to be distasteful and unethical in lieu of a dilated exam. Everybody in their hearts of hearts knows a wide field photo is just as good if not better than a dilated exam in routine cases for most doctors. Why are we leaving money on the table?
3. No show fees. Medicare allows you to charge no show fees. We nor any of the practices I've ever been in have charged it. It would significantly reduce the no show rate and improve the efficiency of our clinic. You can't charge no show fees to medicaid patients. Probably better to give those patients a 3 strikes rule.
I'm sure some of the old timers will see these ideas and shake their heads in disgust. These are the same guys who sold our profession to PE.
I have always found it remarkable how resilient and entrepreneurial our specialty has been over the years. We're fortunate to be able to significantly improve the quality of our patients lives and have patients who value our expertise and service even when CMS does not necessarily do so with their fee schedules. I don't think what we're discussing here needs to be a secret. The more we normalize these types of activities, the better it will be for all of us. What are you guys doing to combat decreasing reimbursement and increased expenses? Are you offering new services that you previously/traditionally would not? Are you charging for things that you did not previously for? How useful/big of an impact are these measures? Has there been patient blowback? Does it feel ethical to you? I'll start.
Refractive surgery fees
1. Astigmatism and presbyopia correction concurrent with cataract surgery. Medicare currently pays around $540 per cataract surgery which has been continually decreasing over the past few decades. It is now at a point where many surgeons choose to not do or only do them as a loss leader for selling patients refractive services. CMS has ruled since 2005 that astigmatism and presbyopia correction are not covered by medicare and thus are billable to the patient. Fees charged can include surgeon/professional fees, lens costs, femtosecond lasers if used, intraoperative biometry, refractive guarantees, eyedrops, lipiflow/amniotic membrane/ocular surface treatments. Many doctors have expressed that they feel like "used-car salesmen" trying to sell these services. I personally provide some of these services and think many of them are worthwhile. It's remarkable to me how much patients are willing to pay for these services and unlike 3rd party payments, I've seen these prices continuing to increase. How much are these fees in your markets?
2. Eyedrops, lipiflow/amniotic membrane/ocular surface treatments. Some of these feel like "snake oil" to me. A lot of doctors are paid big money to promote these activities. I do not do these things on a routine basis.
3. Femtosecond laser/biometry and other out of pocket stuff. I can do great surgery without them but they are effective in many situations and can significantly increase revenue.
4. Comanagement fees. These are actually paid out to other doctors to take care of the patient pre/postop. Sometimes they can include "refractive comanagement" where the other doctor gets paid above and beyond what they can bill medicare/insurance. These can feel dirty to me but in the big cities, you sometimes have to pay to play (if you want these patients which can be lucrative). Ironically, one of my colleagues referred their patient out to do a complex LASIK treatment and he unexpectedly got a comanagement check in the mail to take care of the postop. Sweet.
Afterhours work
1. Hospital call. Traditionally nobody got paid to take call at the local hospital and you would build your practice this way. I've participated in some locales where the doctors that took call got paid a substantial amount of money and other locales where they were payed zip. This sometimes depends on local regulations. Some hospitals require you to take call if you want to use their ORs. Some insurance companies require you to have hospital privileges and the hospitals can subsequently require you to take call even if you don't operate there. I've heard as high at 14,000 per week. The hospitals where I practice don't pay and so I currently do not take call. It would take something in the neighborhood of what was described above for me to even consider it.
2. Practice call. We currently have physicians on call for our practice. Every practice I've ever worked at takes patients phone calls after hours for emergencies (many of them are not emergencies). Why do we still do it (for free)? I know tons of direct primary care / concierge practices that charge their patients an annual fee for priority scheduling, possible weekend visits, being able to text/call their docs after hours. Thoughts about charging a concierge fee to allow after hours calls/exams??
3. Patient calls. Patients will sometimes call during office hours. Not all questions require an in person exam. Thoughts about turning all patient medical calls to telehealth/telephone exams?? Lawyers charge by the hour. There's a mechanism for us, why can't/don't we?
Random fees
1. Refraction. Medical insurance generally does not pay for refractions. Vision insurance will sometimes pay for refractions. Vision insurance pays like $25 for an exam? We don't take vision insurance, we never will. May medicare never "cover" refractions.
2. Fundus photos. I know tons of optometrists who recommend fundus photos for all their patients as a cash pay service. I was "taught" the practice to be distasteful and unethical in lieu of a dilated exam. Everybody in their hearts of hearts knows a wide field photo is just as good if not better than a dilated exam in routine cases for most doctors. Why are we leaving money on the table?
3. No show fees. Medicare allows you to charge no show fees. We nor any of the practices I've ever been in have charged it. It would significantly reduce the no show rate and improve the efficiency of our clinic. You can't charge no show fees to medicaid patients. Probably better to give those patients a 3 strikes rule.
I'm sure some of the old timers will see these ideas and shake their heads in disgust. These are the same guys who sold our profession to PE.
