Real Deal: The Case of the Dilation Dilemma

Doctors and staff are divided on the best timing for this test. Can a compromise be found?

This article originally appeared in the January 2015 edition of INVISION.

Case studies for eyecare businesses

EyeSite, a well-established two-doctor optometry practice in Kansas, was closed for a special meeting early one morning. The doctors, office manager and insurance team sat around a conference table littered with coffee mugs.

Charles, the office manager, kicked off the meeting. “Thank you all for coming in early. We need to find common ground on timing of dilation exams,” he said.

“I’d like to recap the facts before we start negotiating the office policy,” said Andrew, EyeSite’s lead insurance biller. “We know insurance companies consider the dilation exam part of the overall comprehensive eye exam; if the doctor defers the dilated exam to another date, some of our patients have complained about the additional copay.”

Dr. Mary Dodd, the owner, spoke next. “It is better for both the patient and the practice to have a separate dilation exam, and I would like to group dilation appointments together in schedule blocks. It is more efficient for me to keep my mind tuned in to the same task. Dilations are relatively brief visits, so we could keep all four exam rooms filled if we stagger patients in five-minute intervals. It also means we don’t need a full staff in optical during those time frames, since those patients won’t be getting glasses.”

“That sounds great for our production numbers,” Charles said. “We save money on payroll, shorter visits make for happy patients, and we maximize efficiency.”

Mary said to the group, “When a patient needs a dilation exam, I want us to book the appointment six months after the patient’s full exam. It’s similar to dentists, who recommend cleanings every six months — we want to reinforce the importance of healthy eyesight and vision, and it gives me more opportunities to catch and monitor health issues.”

Andrew held his hand up and said, “Wait, I know you have to dilate diabetic patients annually, and a couple of other diagnoses also trigger a dilation. What about those people?”


Real Deal is a fictional scenario designed to read like real-life business events. The businesses and people mentioned in this story should not be confused with actual eyecare businesses and people.


Natalie Taylor is an experienced optometry practice manager for Advanced Care Vision Network and a consultant with Taylor Vision. Learn more at

“I should have clarified that, Andrew,” Mary said. “This discussion is really about dilating ‘healthy’ patients, who represent the vast majority of our patient base. I dilate my ‘healthy’ patients once every two, three or four years, based on a number of factors.”

“OK, and how are we billing these exams?” asked Andrew. “Some patients use a vision benefit plan for their comprehensive exam, instead of their health insurance. If that is the case, is the dilation visit a free continuation of the original comprehensive exam?”

“Of course it’s not a continuation; it should be billed as a medical visit,” replied Mary, slightly exasperated at the question.

Andrew made a skeptical face, but Mary continued her previous thought. “By taking non-emergent dilation exams out of the ‘regular’ day, we can schedule more comprehensive exams, and our wait times will likely improve. It also means patients won’t have to select glasses while they’re dilated, which is obviously inconvenient.”

Andrew shook his head. “I am the one who gets calls from irate patients when we require they attend two visits, pay two copays, and see two insurance claims. The patients sometimes call their vision benefits provider or health insurance company to complain about it, and if the patient has no relevant diagnosis code the insurance companies tell our patients that we are doing something wrong — that a routine dilation is included in the full exam.”

“Remember, Andrew, you are not working for the insurance company, you are working for this practice,” said Charles. “Your department is why we are having this meeting — everyone in the building knows you disagree with a separate dilation exam, and it’s generating drama.”

“I just don’t want to be blamed if we get in trouble,” Andrew said, “and I need to know what to say to patients who complain.”

Mary spoke to the group: “Ultimately, the right answer is always the one that benefits the patient most.”

T H E    B I G    Q U E S T I O N S

1. As an insurance biller, Andrew is clearly experiencing an ethical dilemma. Who do you agree with, and what would you do if you were Mary?

2. How can EyeSite create a new dilation exam policy that works best for the patients and staff?

3. Is the “comprehensive-with-dilation” exam model essential to optometry, or is it creating a barrier to efficiency and profitability?

R E A L    D E A L    R E S P O N S E S

Edina, MN

To make the patient come back for a dilated exam when they have already been in for a routine exam is a hardship for the patient from both a time and a financial standpoint. A better option would be to have the patient pre-style before the exam or look at frames while they dilate. Developing a comfortable, efficient and practical patient experience will go further to increase referrals.

New Kensington, PA

A dilated fundus exam is part of a comprehensive eye visit and should be done yearly on all healthy patients and as often as necessary to monitor ocular pathology, regardless of a patient’s insurance. If picking out glasses is an issue with dilation, have the patients pick their eyewear prior to having the drops instilled!

San Francisco, CA

Whether or not to dilate depends on the standard of care in the area in which you practice. Dilation at the time of the initial visit is by far the most efficient way of proceeding. I begin the dilation before visual field screening. By the time the screening is over, the patient is almost fully dilated. Patients who are looking for new glasses can do frame selection prior to the exam. With frame in hand, after the exam, the costs can be discussed and by that time we’re in full dilation. If the patient is using VSP insurance you cannot bill a separate visit for the dilation. If you do, and bill VSP for a 92004/92014 you run the risk of triggering a VSP audit and possible give backs of comprehensive exam fees.

Portland, OR

I see a benefit to a separate day for dilation, both for the patient and the practice. When the patients get dilated, they are annoyed by the inconvenience it causes if they can’t pick out frames. However, most people would be irritated if they were expecting to get dilated and were told to come back for it and were charged a separate copay for it.

Eldersburg, MD

Dr. Mary is wrong; having the patient back for a dilated exam six months after a routine exam cannot be billed as a medical exam. I also disagree that it is better for the patient to have separate dilated exams. If a patient needs to be dilated, then do it.

Levittown, PA

For healthy patients with no medical diagnosis, the separate visit for dilation cannot be billed to a medical insurance plan. In those cases, if the patient is not looking at glasses that day, then they are dilated that day. If you must bring them back, then it’s at no charge. If they have a medical condition, then the initial visit gets billed to the medical plan and the vision plan is used for the glasses only.