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Real Deal

A Doctor Doesn’t Want to Follow the Rules, How Liable is the Insurance Biller?

She feels like she is doing something very, very wrong and nobody else cares.

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GrANITE STATE EYE CARE, based in southern New Hampshire, was a high-volume private practice with one doctor and ten staff. Gabby was a recent hire; she arrived with extensive billing experience working for a dentist and was offered the position of insurance supervisor. As a recent transplant from Colorado, Gabby had found the state’s job market to be quite narrow and counted herself lucky to have found a billing position. 

ABOUT REAL DEAL

Real Deal scenarios are inspired by true stories, but are changed to sharpen the dilemmas involved. The names of the characters and stores have been changed and should not be confused with real people or places.

ABOUT THE AUTHOR

NATALIE TAYLOR is owner of Artisan Eyewear in Meredith, NH. She offers regional private practice consulting and ABO/COPE approved presentations. Email her at info@meredithoptical.com

After a month of learning about vision care plans and the office EMR software Gabby was functioning independently. Some of the office policies seemed to conflict with what she was learning from third party training sources. For example, the staff were instructed to push patients to return for a separate dilation exam — with additional copay — instead of performing it at the time of a comprehensive exam. Other policies struck her as questionable, like collecting a Medicare 20 percent co-insurance fee regardless of secondary coverage status and then passively leaving any extra monies as a credit on the patient’s ledger, rather than issuing a refund. 

Gabby took some time to gather data from the insurance company websites and took it to her boss Dr. Houghton, eager to show him how knowledgeable she was. This was a great practice in many ways but it needed her help. If she was able to save him from an audit she could be a hero. 

The meeting didn’t unfold as Gabby had hoped. “I’m aware of how these insurance companies want doctors to function,” said Dr. Houghton. “At a certain point we need to start using common sense instead of blindly following orders.”

“Oh, uh, okay,” said Gabby. “I just want to be ready in case we get audited…”

“Let me worry about that if it happens,” said Dr. Houghton. “Audits aren’t the end of the world; we’ll be fine.”

Gabby pulled her papers together to leave. “Gabby, stick with me for another minute,” he asked, then paged Sheila the front desk supervisor. 

Sheila was one of Dr. Houghton’s first hires over a decade earlier. She joined them and settled in next to Gabby. 

“Whenever possible, I want you to start billing both the vision plan and health insurance for a patient’s exam,” announced Dr. Houghton. Sheila jotted down notes on a clipboard. 

“Isn’t that double-billing?” Gabby asked. 

Dr. Houghton scoffed. “Vision plans will pay for the refraction. The medical portion goes to health insurance.”

“I guess I can bill the vision as secondary …”

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“Send them both at the same time,” instructed Dr. Houghton impatiently. “They’re two separate services. Oh, and Sheila, be sure we charge patients the lesser co-pay.”

Gabby felt incredulous but didn’t speak the remainder of the meeting. However, as soon as they were dismissed and out of earshot of Dr. Houghton, Gabby started to vent to Sheila. 

“We aren’t supposed to just not coordinate benefits,” Gabby said, panicked. 

Sheila gave her a sideways look. “He’s the doctor and it’s his business. Why are you getting so worked up?”

“When I submit a claim, there’s always verbiage at the end about how the person doing the billing is liable, and that I can’t knowingly submit incorrect information, or something like that!” Gabby’s face reddened when she saw how little Sheila was actually listening to her. 

 

The Big Questions

  • Should Gabby go along with the wishes of the practice owner, regardless of how he interprets insurance rules? What are her options?
  • When an owner wants to change billing practices but staff aren’t on board, how can the team move forward?
  • In the event the practice does get audited, what is Gabby’s personal responsibility when dealing with auditors?
 

Expanded Real Deal Responses

Robert M. Edina MN

The doctor is right to say that we should not blindly follow orders, however we should be sure we are standing on solid ground. Gabby should recommend to the doctor that he hire an outside firm to do a preemptive fact finding audit and live by their findings. The doctor has every right to bill however he would like. He should make sure that these are legal and accepted practices to avoid great risk. I have seen reports where clinics that were audited had to re-pay insurance claims that were found to be paid in error and fined up to a million dollars plus for using deceptive or unlawful billing practices. Although Gabby could be held responsible for the billing practices it is the doctors practice and I am relatively certain he would be the responsible party.

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Taylor K. Ellington, CT

1  As the employee, Gabby does need to follow the wishes of the practice owner. With that being said, her choices are: to follow the new policy (and continue the old poor ones), discuss the situation with the doctor again and express her discomfort (ideally in a documented meeting with the office manager as well), and/or to start looking for a new place of work.
2. If the doctor wishes to make a change the team is not on board with, the office manager needs to get involved and have a discussion with the team; hear their thoughts and issues, attempt to put them at ease, and then review those concerns with the doctor. A good manager needs to intervene as much as possible when the doctor is doing something unethical. 
3. Based on this conversation, in Gabby’s shoes, she would need to deflect back to the doctor. If she is a certified coder, she should remove herself from this position, so she does not risk damaging her reputation.

Heather B. Fresno, CA

There are two steps. First, find out the truth, is billing for a refraction only to the vision plan while billing the health insurance for the medical part actually ok? She could ask the teachers of her training sessions. Armed with that answer talk to doctor again. Then, second, she has to decide, which I think is to leave because she would be held liable.

Karen L. Orange County, CA

1  Every business owner morally and ethically decides how they want to run their practice. Staff must do as instructed as employees.
2. If discussion and compromise can exist that is wonderful. If not, staff have every right to look for another position. Reason: the practice policies are making them uncomfortable and open to liability.  
3. When the audit comes, take the military “I was just following orders” route and then shut up. BUT if she has a license or accreditation it may be in jeopardy. There are still some “golden rule” practices out there — and they appreciate their staff — go find one.

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Jen H. Sandpoint, ID

Bad, bad, bad. Gabby’s already tried polite confrontation, so she should probably resign. This whole situation sounds super sketchy, and if auditors can prove she knowingly went along with any of these practices, she could be at least partially liable. In one instance where our doctors and billers had conflicting opinions, we shot a few questions over to an unbiased third party. Our EHR system (RevolutionEHR) provides us with complimentary consulting on various topics through their team of doctors, billers, and industry experts. Having an available, expert third party helps when you’ve got someone in authority who is tempted to veto a lower level staff member’s research. (Humility on all sides and good teamwork are crucial too, of course.)

Martha D. Wheatfield, IN

I would not under any circumstances bill the way the doctor is insisting on billing. If you know it is wrong, it doesn’t matter if he is your boss, it is still wrong. If I know better, I wouldn’t be able to do it. I am not sure if you are legally liable or not but I can see the doctor could get audited and throw the actual billing person under the bus. I have met some unscrupulous doctors who would do that. If the doctor doesn’t want to listen when you tell them the correct way to bill insurance companies, no matter how much I love my job, I would have to quit. Places who do this double billing are a lot of the reasons our insurance cost are so high.

 

What’s the Brain Squad?

  • If you’re the owner or top manager of a U.S. eyecare business serving the public, you’re invited to join the INVISION Brain Squad. By taking one five-minute quiz a month, you can get a free t-shirt, be featured prominently in this magazine, and make your voice heard on key issues affecting eyecare professionals. Good deal, right? Sign up here.
  • Natalie Taylor is an experienced optometry practice manager for Advanced Care Vision Network and a consultant with Taylor Vision. Learn more at tayloreye.com.

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    Real Deal

    What Would You Do If You Were This Office Manager Who Caught Her Doctor and Optician in a Sneaky Sun Swap?

    Rx lenses are made but they never get dispensed so that a plano sun gets covered by insurance.

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    WEST VIRGINIA’S BALFORD Vision Center had recently hired their first practice manager, Ellen. She moved to town specifically for the opportunity, bringing nearly 20 years’ experience. The small staff was eager to impress, yet anxious at the prospect of Ellen exposing various flaws and inadequacies.

    ABOUT REAL DEAL

    Real Deal scenarios are inspired by true stories but are changed to sharpen the dilemmas involved and should not be confused with real people or places. Responses are peer-sourced opinions and are not a substitute for professional legal advice. Please contact your attorney if you have any questions about an employee or customer situation in your own business.

    ABOUT THE AUTHOR

    NATALIE TAYLOR is owner of Artisan Eyewear in Meredith, NH. She offers regional private practice consulting and ABO/COPE approved presentations. Email her at info@meredithoptical.com

    One day Ellen was covering the lab while optician Leslie took her lunch break. A patient arrived for an eyewear dispense, and Ellen reviewed his tray: a sporty, wrapped frame with G-15 polarized lenses. Ellen also found a baggie containing an additional set of heavy, clear lenses.

    She checked both pairs in the lensometer and popped back out to see the patient.

    “Sir, I just need another moment. Your glasses are here but I need to insert your prescription lenses into the frame,” she said with a smile.

    “No, no, I don’t want the prescription,” he replied. “The other person said she was going to give me the plain lenses so I’d have sunglasses to wear over my contact lenses.”

    Ellen cocked her head to one side. “Strange. I wonder why she made you lenses,” she said quietly. “Well, I will go get your sunglasses for you!”

    Ellen spent some time adjusting the man’s frame and once more confirmed he didn’t want his prescription lenses. As he stepped out, Leslie walked in.

    “Hey!” said Ellen amiably. “Can I ask you about that guy’s order?”

    “Sure, what’s up?”

    Ellen grabbed his tray and started rifling through it. “Why did you order prescription lenses, but not dispense them? He told me he just wanted the demo sunglass lenses.”

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    “He wanted to use his vision plan,” explained Leslie.

    “Oh,” said Ellen, and paused. “I guess I don’t understand.”

    “Well, they don’t allow patients to buy plano sunglasses, so I just order a pair of lenses that are completely covered or just have the minimum copay, then swap the lenses out when they come back from the lab and throw them away,” she said matter-of-factly. “If they have a co-pay, we deduct that from the frame copay so they aren’t paying anything extra. Patients are fine with waiting, as long as they can use their plan.”

    Ellen nodded slowly. “Is that what the doctor wants, or is that your own workaround?”

    “Yeah, Dr. Balford told me to do it that way,” said Leslie.

    Ellen sat down with the practice owner a few hours later to explain the situation and her concerns.

    “We can’t order lenses with no intention of dispensing them,” explained Ellen.

    Dr. Balford shook his head. “I don’t remember ever discussing this,” he confessed. “But it seems silly not to be able to give the demo lenses to a patient — it should be considered a part of the frame purchase!”

    “If we get audited, there’s a risk our contract will get canceled,” warned Ellen.

    “That’s a big ‘if,’ Ellen.”

    “You have also encouraged an employee to commit insurance fraud. I reviewed our records for the last 12 months and I see 20 instances of Leslie processing fake lens orders,” she said. “We need to take action of some kind.”

    Dr. Balford shrugged his shoulders. “I feel like this is a gray area — I’m not convinced we should change anything.”

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    The Big Questions

    • Do you agree with Dr. Balford that demo lenses should be included as part of the frame purchase?
    • How do you protect the business if it gets audited by the vision plan in question?
    • If you were in Ellen’s position and Dr. Balford elected to continue this policy, what would you do?
    Jess G.
    Leesville, LA

    Patients are responsible for any eyewear purchase that is not covered by their allowance plan. If they don’t need prescription eyewear, they should re-evaluate the money they are spending on their monthly vision plan premium compared to what they would pay out of pocket for an eye exam and plano sunglasses and ask themselves: “Is this vision plan really saving me any money?”

    Cory S.
    Las Vegas, NV

    As frustrating as it may seem, most vision plan contracts prohibit this type of activity. The intent is to defraud a vision plan. If there is a plano sunwear option it will be stated in the benefit. You will not only lose your contract, but also face heavy fines, penalties and possibly legal action. Something similar would be for a patient to “give” their frame to a friend or family member. This also constitutes fraud. Better have your ducks in a row to show you were not complicit in the scheme.

    Caitlin W.
    Montrose, CO

    I would not be comfortable with the situation at all. Letting patients know that is insurance fraud would be my first step. Also, most companies will write out the policy, which I would show to the patient and explain why it is not something we are willing to do at our practice.

    Missy D.
    Spokane Valley, WA

    We always let the patient know what their insurance benefits are. If their prescription is valid for lens coverage but the patient just wants plano sunglass lenses, we explain that we will need to fill the lens prescription to utilize their lens benefit and we dispense the eyewear with the prescription lenses mounted in the sunglass. We give the patient the stock plano/demo sunglass lenses and let them know if they don’t like the prescription in the sunglass after giving them a try we can mount the plano/demo lenses back in. We’ve used their benefit according to their plan, explained coverage to the patient but also allowed the patient to keep all parts purchased. The original stock plano/demo lenses were part of the frame the patient is purchasing (even if they are using their insurance coverage), so they should be allowed to keep them. It becomes up to the patient after that, what they do with those lenses.

    Pat R.
    Irving, TX

    According to both VSP and EyeMed this is fraud. We don’t do it where I work. We have patients try and we tell them no. However, as long as the patient is really getting prescription lenses they will actually use, I don’t mind giving the plano lenses to them for future use if they can no longer use the Rx lenses.

    Judy M.
    Pittsfield, MA

    I would give demo lenses with a sunglass frame. I would not order Rx lenses knowing the patient is not going to use them at all. I do agree with the doctor to give the demos to the patient as long as they have ordered Rx lenses that they will use. The reason I give demo lenses is if in the future the customer wants contact lenses or to let someone else have the sunglasses, they have the demos. If the business gets audited, they will have to face the consequences. If I were Ellen and the doctor wanted to continue this practice, I would look for another job.

    Judy C.
    Virginia Beach, VA

    The doctor and optician may consider it a gray area, but the vision care plan will not. Fraud is fraud, no matter how well intentioned. Another big “if” is the patient seeing another, different practice and expecting the same “help.” One complaint to his vision care plan about perceived unfairness will surely trigger an audit and will definitely expose other discrepancies for as many years as are investigated. Regardless of the doctor’s actions, the office manager should document both her findings and her conversations about the issue with the doctor. Whether the office manager stays or leaves is a personal choice, but she must understand that her professional reputation will be at risk if and when an audit is done. In addition, she may be liable for hiding the fraudulent claims.

    Jennifer L.
    Dansville, NY

    You have to abide by the contract you commit to with the insurance company. If they do not allow plano eyewear you must not make a revision so they can get plano eyewear. I also believe that when you sell a plano pair of sunglasses then Rx them, that person bought the demos with it — give them to them. If they decide later to swap out the Rx lenses for the planos then do it. It’s ridiculous to nit-pick some of these things but you have to honor the legal contract you agree to. Explain the situation to the patient, how illegal activity can shut down your business, and how important it is for you to be legit. Tell them you can’t control what they do when they leave the office or in the future, but what happens in your office is always above board and transparent. Your reputation and integrity are top priority.

    Leisa L.
    Newport Beach California

    Where a patient uses their insurance plan for sunglasses and the frame has plano lenses mounted the lenses are part of the frame purchase and should be at least offered to the patient when dispensing the completed glasses. If the patient also wears contact lenses and decides to use the plano lenses that is their choice. If a pair of lenses are cut for the patient that are not actually the patient’s Rx, that is a completely different situation. It should not be considered insurance fraud when making the proper Rx for sunglasses. There are other ways to handle the sunglass sales. Recommend two different pairs, one for wearing over the contact lenses and a second Rx pair without the contacts. In fact, there have been several sunglass frames made with pop-out lens ability just for this purpose. The Porsche Carrera and a Cazal come to mind immediately.

    Rigo L.
    Indio, CA

    Wow, this is a tough one, depending on how you see it or how you work the insurance. Where insurances don’t pay much, in a small private office where we want to make some money off insurances, why not? On the other hand, I have worked in a larger practice with multiple locations where this was out of the question. I don’t see a fraud issue as long as the patient has the minimum Rx, they understand what we are doing and the lenses get dispensed. Where it becomes a very dark gray area is when you are trying to save the patient money and you bill the insurance for a different frame and not dispense the lenses. Even though the patient has an Rx you are basically lying to the insurance company and this can be a big issue. In Ellen’s case she sounds like, and I could be wrong, an old school optician. There is nothing wrong with that as long you are good with, and open to, change.

    Stewart G.
    San Francisco, CA

    1) VSP guidelines state that the demo lenses are not to be given to the patient. So, the answer is no.
    2) You can’t protect the business. The business has committed insurance fraud. And VSP guidelines are such now that they can go back years and request you pay them back for all those orders plus interest plus penalties AND you can get kicked off the roster.
    3) Ellen may need to put what she said in writing to protect herself, or start looking for a new position in a different office.

    Pablo M.
    Alpharetta, GA

    1. No, we do not hand out the clear demo lenses, so why do the color ones? It is supposed to be an Rx job for insurance purposes, right?
    2. How do you protect the business if it gets audited by the vision plan in question? Turn witness for the prosecution, your honor…
    3. I would try to explain to the good doctor why this is all a bad idea all around, and if the doctor decides to keep doing it, it will be without my help. I deal too much with insurance as it is to get involved in these kinds of messes.

    M. Pastor
    Phoenix, AZ

    In this scenario, Ellen is completely correct! The doctor/owner is a complete idiot and should not be in business if he is willing to commit insurance fraud! Ellen, find a new job with an ethical practice!!

    Donna
    Mission, British Columbia

    I would never do this; it’s insurance fraud. My credentials and reputation are worth way more. I would never protect or work at a place that allows it.

    What’s the Brain Squad?

    If you’re the owner or top manager of a U.S. eyecare business serving the public, you’re invited to join the INVISION Brain Squad. By taking one five-minute quiz a month, you can get a free t-shirt, be featured prominently in this magazine, and make your voice heard on key issues affecting eyecare professionals. Good deal, right? Sign up here.

    Continue Reading

    Real Deal

    If This Team of Expo Slackers Worked for You, What Action Would You Take?

    They spent most of the all-expenses-paid trip in the hotel bar.

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    DR. BENNIGAN’S STAFF of 12 was buzzing. Liz, the office manager, was spreading the word that for the first time ever the practice would be sending some team members to a big optometry conference. The lucky staff members would fly from their home in Lexington, KY to Atlanta, GA for three days of continuing education, special events and expo exhibits.

    ABOUT REAL DEAL

    Real Deal scenarios are inspired by true stories but are changed to sharpen the dilemmas involved and should not be confused with real people or places. Responses are peer-sourced opinions and are not a substitute for professional legal advice. Please contact your attorney if you have any questions about an employee or customer situation in your own business.

    ABOUT THE AUTHOR

    NATALIE TAYLOR is owner of Artisan Eyewear in Meredith, NH. She offers regional private practice consulting and ABO/COPE approved presentations. Email her at info@meredithoptical.com

    Liz asked everyone to email her a short “essay” describing why they wanted to attend and what they hoped to get out of the experience. Based on these essays Dr. Bennigan chose four staff—two opticians and two technicians—plus Liz to lead the trip. She immediately booked the flights so the group could sit together. Dr. Bennigan agreed to pay each staff person their regular wages for an 8-hour workday. Liz carefully scheduled each staff person with CE lectures as well as time to attend the expo. She printed the course handouts and made binders for each attendee.

    The morning of the flight Liz met her four co-workers in the office parking lot and everyone loaded into an airport shuttle van. It was early, just after dawn. As they pulled out onto the highway Liz shushed the group to go over some of the details, beginning with her binders.

    “I’d recommend reading through your handouts on the plane,” said Liz. “Dr. Bennigan has scheduled a 3-hour staff meeting for when we get back home, and each of us is going to need to present a 3- to 5-minute summary of what we learned at each lecture.”

    The group collectively rolled their eyes and shifted in their seats, but no one argued.

    “Tomorrow night at 7:30pm we are going to meet up in the hotel bar and walk across the street to a restaurant so we can talk about the first day, okay?” The girls tiredly sipped cups of coffee and stared out the windows.

    Liz was booked in a room by herself and spent the first night zoned out in front of the TV. The next morning, she saw one of the opticians on the shuttle bus.

    “Where’s your partner in crime?” Liz asked amiably.

    “Oh, we met up with a few of my old co-workers at a bar last night. She got pretty drunk,” the optician said, chuckling. “She’s still out cold; I left her in the room.”

    “Oh boy,” Liz tried to hide her frustration.

    That evening, Liz waited for her team as planned but by 7:40pm she sent a group text asking for an ETA.

    “I forgot!” wrote the technicians. “We’re at the big optometry party – come here!” “We have drink tickets!”

    “We’re too tired,” texted one optician. No reply from the other.

    Liz called the restaurant to cancel their reservation, and backed off the group for the remainder of the trip.

    At Dr. Bennigan’s staff meeting the presentations were of varying quality: one of the technicians did an adequate job, but the other had clearly not taken any notes during her classes. The two opticians confessed to missing several classes and largely worked off the handout binders.

    Dr. Bennigan held the four back for a recap. “Ladies,” he began, “Liz and I are not satisfied with your efforts—not today, and not while in Atlanta. I was OK paying you for the time you put in to your education, but you clearly have taken advantage of the situation.

    I think we need to revisit the terms of this trip.”

    The Big Questions

    • Would it be fair of Dr. Bennigan to subtract from an employee’s daily rate for each missed course?
    • Should the team be held accountable for missing team-building events? How?
    • If Dr. Bennigan decides to send staff next year, what should he do differently?
    Becky M.
    Osawatomie, KS

    We have to show proof that we attended our classes. If we don’t have our schedule stamped we don’t get paid for the time in that class. The staff should not be paid for the classes they did not attend. The staff was disrespectful for not attending the dinner they were aware of ahead of time. If the doctor sends staff next year he should spell out, in writing, what is expected of staff and none of the staff that attended this year aside from Liz should be allowed to attend again. We have never had to put the expectations in writing at our practice. We have a lot of fun at conferences but we also attend our classes and take notes because we’re being paid to be there and our doctor is paying for CE. Common courtesy and respect.

    Thomas W.
    Myrtle Beach, SC

    The doctor paid the staff to attend the classes. They did not attend, so it would be fair for him to subtract for each missed course. The team should be held accountable for missing the team-building events, but as these were clearly after hours and not during their paid work hours, there should be no financial consequences for missing these events. If the doctor decides to send staff next year — and I think he should—he should personally explain his expectations to the staff. Additionally, it would be wise for him to attend the conference along with his staff. It would also be a good idea for him to take them out to dinner as a team-building event and not as a business meeting. I would encourage keeping the team together as much as possible. The office manager zoning out in front of the TV by herself is not acceptable.

    Deanna A.
    Fort Collins, CO

    Express your concerns and document it in their employee file. I would consider sending less people the following year and certainly not the ones who didn’t follow through. There seemed to be a lot of hand holding and trying to make sure they follow through. There needs to be some point of responsibility of the employee. They go to learn and share. The partying and missing classes is abuse of the situation. Next year if they miss class, then they would be docked those hours and asked to reimburse for the cost of education.

    Brian C.
    Prescott Valley, AZ

    We had a similar situation when I took my entire staff of five to Vegas Expo West about 20 years ago. Most of my staff did not attend the education I paid for, and were off drunk/gambling the entire time. Time dedicated to purchasing new frame lines and evaluating equipment was spent trying to find errant employees who were passed out/vomiting in their rooms after the “Marchon party.” It was a terrible experience. I was furious that I closed my clinic for three days (thousands in lost revenue), paid for the entire thing (a couple more thousand dollars), the staff’s hourly wage for three days, and I netted no positives at all. It was a complete waste of time and money. The staff noted my resentment for years afterward, and never brought up going to Expo again. I have never paid for any employee to go to Expo since. I attend it alone, sober, and only for one day.

    Chris D.
    Tampa, FL

    I would not touch the employees’ pay for the trip. But not having filled the agreed requirements, I would suspend them for three days for gross negligence of their duties. This was not vacation; this was work and education. The expectations were set. They failed to deliver — three of them, at least. I would bar them for one year for any company paid events or education. I wouldn’t rub their noses in it, but set the tone to know it will never be tolerated again. And why.

    Cherlyn F.
    Decatur, IL

    Speaking as an office manager, I would write up the employees who did not participate according to the agenda. I would also forbid them from any future trips for a period of time, say one to five years. Our policy on continuing education: Continuing education and the expenses involved will be left to the discretion of management. There may be times when you will be required to attend a seminar scheduled after office hours, or on a Saturday or Sunday. The doctors will pay your registration fee, and you will be reimbursed hourly pay for time spent in classes and for two hours for exhibit hall time. No reimbursement for travel expenses will be considered.

    Pamela M.
    Highland, CA

    1. Would it be fair of Dr. Bennigan to subtract from an employee’s daily rate for each missed course? ABSOLUTELY.
    2. Should the team be held accountable? YES.
    3. No further out of area continuing education except for the staff person who adhered to the rules. No exceptions for staff members who took advantage of their employer and office manager. The staff, despite the rules, took this as a vacation at the employer’s expense. Shame on the employees. This breach of trust has now created an office problem and will remain as part of the employees’ records. Trust will have to be earned back, if that is possible, and it is up to the doctor and the office manager.

    Taylor K.
    Ellington, CT

    1. Yes, it would be appropriate to subtract the daily rate for missed courses. The staff was being paid for the hours they were attending the conference/expo, so why would they be paid for not going? Especially considering typically you pay per credit hour, so not only would the staff be paid to not be working, they were wasting money for attendance fees.
    2. While it is frustrating the team didn’t attend, if they weren’t being paid for that time, there isn’t much to do for this specific issue, unless staff was told it is mandatory.
    3. I would call a meeting with the doctor and the attending staff and express disappointment with what transpired. I would then explain that I will not be considering any staff members who missed courses for the next education trip. In the future, having very clear expectations of the staff will be essential.

    Judy C.
    Wilkes-Barre, PA

    Yes, the doctor should hold the staff members accountable. Rather than docking their pay, it should be considered during their annual review process and the costs reflected in any resultant pay increase. I also believe there should be a written agreement between the doctor and any staff members attending a conference stipulating what will be required during the event. I would hope that any staff members offered this opportunity would jump at the chance. I know I would have.

    Pam P.
    Downers Grove, IL

    It’s disappointing when a staff member does not value an opportunity like this! However, without expectations set prior to the trip, I don’t know that it would be fair to not pay for something promised. Spelling out expectations and letting staff select classes that might interest them, or covering CE requirements if they are certified, would give staff the ability to decide if they could meet the doctor’s expectations. Additionally, it should have been noted that any missed classes/days/activities that are required (and most likely already paid for) would result in a reduction of any reimbursement or pay. Working together as a team to cover any aspects of the meeting the doctor needed information about would have benefited all. But the girls all missing the meeting Liz had asked them to attend at the end of the first day could have derailed plans for the following days and was blatantly disrespectful to Liz. Action might be considered in that respect. The staff acted irresponsibly.

    Martha D.
    Wheatfield, IN

    I definitely think he should subtract some of the hours for the ones who didn’t attend their classes. They didn’t live up to their part of the bargain. If he does send anyone next time, I would draw up paperwork specifically letting them know what is expected of them and what is expected of the doctor and have everyone sign. That way, when they come back afterwards and the doctor goes over the conference with them, all parties will be held accountable. If I was the doctor, I would have been really upset with my staff; they were chosen to go and all they did was play around.

    Dennis I.
    Monroe, CT

    The doctor should have laid out all expectations and consequences prior to the meeting. This way, if someone didn’t fulfill their duty, there would be no questions regarding consequences. The staff manager should not only have made sure the staff met for an appropriate meeting, but also allowed for free time. Because the doctor and manager did not lay out their expectations, the only consequence should be that the individuals do not qualify for another trip.

    Rigo L.
    Indio, CA

    This is funny, and at the same time sad but true. The staff should be held accountable for this. There is no reason why the doctor has to pay/lose for their staff to party. The staff should be ashamed, but I understand how things got out of hand. I give props to the manager for not trying to babysit her staff. I would subtract their pay — they would understand why. They need to understand that this is not acceptable. If they get bonuses, I would consider skipping them or cutting them significantly. I would also consider a write-up as well. As for the following year, I would still send staff but not those same staff ever again. There is no room for immature staff.

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    If you’re the owner or top manager of a U.S. eyecare business serving the public, you’re invited to join the INVISION Brain Squad. By taking one five-minute quiz a month, you can get a free t-shirt, be featured prominently in this magazine, and make your voice heard on key issues affecting eyecare professionals. Good deal, right? Sign up here.

    Continue Reading

    Real Deal

    Ever Feel Like Your Billing Policy Is Backfiring?

    This practice does. How can it get back on track?

    mm

    Published

    on

    IN FOCUS VISION CARE, a private practice in Olive Branch, MS, was adding a new billing manager to the office. Sean had four years of experience submitting optometry claims and 12 years billing for a physical therapist; this would be his first position as a supervisor. Erin was office manager and spent a lot of time training Sean during his first few weeks. After lunch on his third day, Erin brought Sean to the conference table and spread out several documents.

    ABOUT REAL DEAL

    Real Deal scenarios are inspired by true stories but are changed to sharpen the dilemmas involved and should not be confused with real people or places. Responses are peer-sourced opinions and are not a substitute for professional legal advice. Please contact your attorney if you have any questions about an employee or customer situation in your own business.

    ABOUT THE AUTHOR

    NATALIE TAYLOR is owner of Artisan Eyewear in Meredith, NH. She offers regional private practice consulting and ABO/COPE approved presentations. Email her at info@meredithoptical.com

    “I’ve delayed going over Medicare but I think it’s time,” Erin began. “We made a decision that doesn’t really seem to be panning out for us, so you and I need to work with the doctors to edit our protocol.”

    Sean was intrigued. “I’ve always known Medicare to be straight-forward. What’s happening?”

    Erin pulled one of the documents toward Sean: an EHR-generated pie chart. “As I mentioned earlier, 44% of our comprehensive exams in the last five years have been Medicare exams. Eighteen months ago we saw a major increase in Replacement plans.”

    Sean nodded. “Right, patients on Medicare can buy a hardware benefit. I’ve seen this advertised on television.”

    “Well, the plans these patients pay for also include a well-visit.”

    “The doctor I used to work for always sent the exam to Medicare. I understand these plans to be for optometrists to ‘identify – don’t treat.’ Elderly patients usually have a medical diagnosis and require actual care.”

    “I agree with you. Their comprehensive exams are, on average, too complex to bill to these kinds of plans — not to mention the significant difference in reimbursement!”

    “So what’s the issue?” Sean asked.

    “Several patients complained, first to our doctors and then to me, that they wanted to use the services they had purchased. Most of the patients I spoke to were in their early 60s and relatively new to Medicare. One patient even went to our local newspaper and got a reporter involved. ‘Potentially deceptive practices.’ We were pushed into the spotlight.” She sighed, pulling the newspaper clipping out of the pile towards Sean. “We did what we thought was best at the time: the doctors only do a refraction and the minimum level required for the Replacement plan, delay all patient counseling and education, then schedule a comprehensive visit using Medicare for a few weeks later.”

    Sean nodded. “That sounds reasonable. The patient uses both plans and I imagine at the second exam you skip the refraction and only collect the 20% co-insurance?”

    “Yes, but the problem is most patients are no-showing to those exams, or canceling last minute and never rescheduling. We’re now seeing these initial patients pass the 12-month mark and call to book again. One doctor believes as long as we document carefully and have a signed consent that each patient understands the difference between the well-visit and a comprehensive exam, it’s the patient’s right to select their level of care. The other doctor told me she plans to refuse well-visits for patients who skipped their Medicare-level exams last year, because she doesn’t think a piece of paper will protect us from the consequences of subpar health care.”

    Sean drummed his fingers on the table. “I think I need to do a little research before bringing my professional recommendation to the doctors,” he said.

    The Big Questions

    • How would you have solved this dilemma if it was your practice criticized in a newspaper?
    • If your parent/grandparent was a patient at this practice and wanted to use a Medicare Replacement plan, which doctor would you side with?
    • Would your own protocol be affected if your Medicare base was only 10%? How about 80%?

    Real Deal Responses

    John M.Victoria, TX

    I recommend the practice stop participating in the Medicare advantage plan and see patients that have regular Medicare.

    Nina C.North Chesterfield, VA

    This is hard. I would like to do the wellness on the vision plan, but Medicare patients have more complex ocular situations than most. We have a large Medicare group. Most will not return for the Medicare exam and liability is such that I cannot give a “lesser vision exam.” We tell patients when making the appointment and again on checking in that we are Medicare providers and will be filing Medicare. We will be collecting refraction fees unless the patient has a vision plan that coordinates benefits to cover refraction. We can use their material benefit towards glasses or CLs. Those who disagree never make an appointment or leave. If the optometrist was to forsake filing Medicare, we would soon be dropped as physician providers.

    Rigo L.Indio, CA

    Newspaper! Who reads a newspaper nowadays? Anyways, it could have been worse with social media or TV. Patients with Medicare usually require extra time and visits and they think Medicare works the same everywhere. I have seen offices take Replacement plans with Medicare only if they have a vision insurance plan and refer out for medical exam or not take Medicare at all if it’s a Replacement plan. Well visits don’t do much for a patient and most of the time they need comprehensive exams or medical during an office visit. That being said, I would change protocol for the Medicare patients to only see them for comprehensive or office visits. I make that clear when the appointment is made. Having a good relationship with MDs and co-managing patients works best.

    Maureen G.Oak Park, IL

    I see the problem as one of a lack of educating the patient. Our office sees maybe 10 percent Medicare patients, but the doctor takes time to explain so the patient understands the importance of the medical visit. We have few if any patients that do not schedule a medical visit. And it has to be the doctors doing the explaining, not a manager or technician. Patients will listen to a doctor more than anyone else.

    What’s the Brain Squad?

    If you’re the owner or top manager of a U.S. eyecare business serving the public, you’re invited to join the INVISION Brain Squad. By taking one five-minute quiz a month, you can get a free t-shirt, be featured prominently in this magazine, and make your voice heard on key issues affecting eyecare professionals. Good deal, right? Sign up here.

    Continue Reading

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