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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

    How Should an Office Handle this Disgruntled Patient with Unpaid Bills and Ongoing Medical Needs?

    The doc wants to keep treating him and hopes to erase that negative online review despite his overdue balance.

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    DEENA, BILLING MANAGER at Rose Family Vision in southern Rhode Island, was reviewing an accounts receivable statement when her extension rang.

    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

    “Hi Deena. You asked me to tell you when Edwin was about to check out. Can you come to the front desk?” said a receptionist.

    “I’ll be there in a minute,” she replied, grabbing her clipboard.

    Edwin, an older gentleman, was pacing the showroom when Deena arrived. He saw her and nodded in recognition. “Nice to see you again, Edwin,” said Deena, extending her hand. “Let’s sit someplace quiet.”

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    Deena escorted Edwin into an empty exam room and closed the door. “So, I know you had your eye exam today with Dr. Rose,” she said, “and we still have the glasses you ordered in 2017.”

    Edwin rolled his eyes, both annoyed and embarrassed.

    “You paid half, but you do still owe $240 on these glasses, and we have a $15 monthly late fee which has essentially doubled your bill,” she said slowly. This elicited a short expletive from the patient, but Deena continued. “At your insistence, Dr. Rose agreed to schedule your appointment today and will bill your insurance, but we do need to address this past due balance.”

    Edwin leaned forward in his chair. “I was hospitalized for a month and couldn’t get my glasses when they were ready, then I was recovering, and then I started getting the late fee bills and harassing phone calls, and decided I didn’t want them anymore,” he huffed.

    “Yes, I did read that in your online review,” Deena said delicately, pulling from her clipboard a printout of the two-star evaluation. “However, glasses are custom made for you, and as I had said last year, we can’t cancel an order after it is completed.”

    “Those glasses are useless now,” he replied. “I got cataract surgery down in Florida last winter and the prescription is completely different now. Why should I pay for something that I can’t even use?!”

    Just then Dr. Rose knocked gently on the door and came in.

    “Hi Edwin. Hi Deena,” she said gently, sensing the tension. “I wanted to join the conversation after today’s exam.” She took a seat next to Edwin and faced Deena. “Edwin needs a LipiFlow treatment, and we discussed using CareCredit to make that happen.”

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    Deena looked at her boss, dumbfounded. Awkward silence followed.

    “Edwin, why don’t you come out with me, one of our staff is going to explain CareCredit and help you fill out the application paperwork,” said Dr. Rose.

    Deena stayed put. Dr. Rose returned a moment later.

    “I know what you’re going to say,” began Dr. Rose, “but he needs medical care. Attach the optical bill to the new charges and put it all thru CareCredit, if that makes things easier for him.”

    “What a mess,” moaned Deena.

    “We need him to change that bad online rating,” said Dr. Rose. “It’s killing our average.”

    “I’d rather fire him as a patient,” she replied.

    “Come on, Deena,” Dr. Rose scoffed. “I need you to get Edwin back on our side.”

    The Big Questions

    • What can Deena do about the outstanding optical bill and “useless” glasses?
    • Should an outstanding optical bill ever block ongoing medical care?
    • If you were Dr. Rose, would you have done anything differently?
    Craig F.
    Rushville, IN

    I think Dr. Rose should have made this suggestion to Deena away from the patient. It would have put Deena in a less awkward position. Also, Dr. Rose should have backed up Deena and told Edwin he needs to pay for the glasses. If Edwin is belligerent, ask him to pay 50 percent of the glasses cost. That should cover the costs of making them.

    Nikki P.
    Gunbarrel, CO

    Look at the actual frame and lens cost to the practice; how much did the practice lose? Charging him that amount may be a good compromise and no one is at a total loss. An outstanding optical bill should never block ongoing medical care. If Dr. Rose had already discussed his options with him and both agreed CareCredit was the best solution, Dr. Rose should have told Deena immediately and assisted Deena in the conversation the whole time to ensure a smoother conversation.

    Barry S.
    Seaford, NY

    Opticians should become more aware of just what their added value is to an “eyeglass product.” If you subtract this added value, you come close to what online would charge for the same materials. So, if the buyer/patient isn’t receiving this added value, why are they being billed for it? It seems to me that the years of control we’ve had over the eyewear transaction have imbued most offices with a sense of entitlement to the buyer’s dollars. If nothing else, the situation described speaks volumes for separating the eyewear purchase from eye-based medical care. In any event, hope they enjoyed punishing the client for not picking up the eyewear and paying in full for it. I think we can all agree that the 50 percent deposit more than covers the lab costs for the lenses, while the frame can…well, you know. Think about it.

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    Gigette H.
    Washington, NJ

    My office has patients pay in full prior to processing any order of eyewear. We have a cancellation policy and a restocking fee policy. We state on the back of our superbill all the policies regarding payments, refunds and warranties. We also research deductibles, copays and coinsurances extensively prior to the patient’s visit. My staff and the patient know the patient’s financial responsibility at the time of service. Because of the work done pre-appointment, we have almost no billing afterwards. After years in practice, I try to be prepared for most eventualities.

    Craig L.
    Coconut Creek, FL

    After six months of not picking them up I would donate the lenses and write the rest off. You did not lose money. The deposit covered the cost of the lenses and the patient has nothing. I would then note on his chart in the future that he must pay in full upfront from now on. I would never bring it up to the patient. They lost $250 and have nothing. The patient is always first, and the profit comes from good optical karma!

    Greg K.
    Dodge City, KS

    The situation should have been handled within 90 days of the original order unless the extenuating circumstances had been explained to the office. Multiple attempts to communicate with the patient should have been made. If no response, then the frame could have been returned to inventory to reduce the patient’s balance and the “custom” lens cost remains the patient’s responsibility. We bend over backwards to accommodate a patient’s needs and situations, but with no explanation from the patient, at the 120-150 day mark the account should have been turned over to collections. At that point, all future orders are paid in full on the day of the order.

    Lynnette G.
    San Mateo, CA

    I too would’ve taken the patient to a quiet place and reviewed the charges. 1. Offer to remove the monthly service fees, allowing the patient to pay the original balance with CareCredit. 2. With his Rx change, depending upon the new Rx, offer to redo the lenses to a single vision lens in an Rx for whichever works best for the patient (no additional cost/SV lenses are relatively inexpensive). 3. Sign the patient up for CareCredit and wrap the remaining balance up into CareCredit. 4. Meet with the doctor prior to the visit and discuss what she was doing/set up a protocol with regards to handling patients. There is no right answer and communication is key.

    Stewart G.
    San Francisco, CA

    First of all, the practitioner should never have come in and changed the conversation without consulting his office manager first. It completely undercut the OMs credibility. Alternative forms of payment should be presented in a unified manner. Given how long the glasses had not been paid for, there should have been rules within the practice to handle this: It should have been sent to collection and/or a dismissal letter sent so that the review should be superfluous. This way, the bad review could have been discussed online because the patient is no longer a patient of the practice. If none of this is an option, treat the unpaid bill as bad debt and ask for all payments in full in advance of any services being rendered to the patient.

    Judy C.
    Virginia Beach, VA

    How badly do you want to retain the patient? 1. Update the Rx in the glasses he ordered two years ago. 2. Put everything including his medical treatment into CareCredit minus the late fees. 3. No one should ever withhold medical treatment. Ever. 4. Happy patients tell everyone they know how happy they are. 5. Unhappy patients tell anyone who will listen how unhappy they are. The practice has all the control in this case.

    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.

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    Real Deal

    How Did This Trunk Show Turn Out So Wrong?

    They had such high hopes: What can the practice do better next time?

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    FUNG EYE CARE WAS an established optometry clinic on the outskirts of St. Louis, MO. Dr. Fung and her two partners employed 20 staff, a few of whom had just returned from an out of state conference. Lead opticians John and Mike were buzzing about all the new frames at the event, and asked to meet with the doctors to discuss an idea.

    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

    “We would really like to throw a trunk show at the office,” said John.

    “John and I will do all the prep work, but we want to do it the Friday afternoon before Labor Day weekend, from 3-6 p.m.,” said Mike.

    “We’ve never done something like that before,” said Dr. Fung. “Where would we start?”

    “Normally two doctors see patients Friday afternoons. I’d like to reschedule the last two hours and block that time out, so if someone comes to the event without an active prescription they can be seen immediately,” John replied.

    Dr. Fung looked at her fellow practice owners, who nodded their agreement. “Okay guys, I like your confidence! Obviously, there’s some pressure to be profitable to make up for the lost appointment times, but an event could be a lot of fun for the community,” she said.

    John and Mike spent the intervening five weeks in party planning mode. Two of their frame reps with multiple lines agreed to attend. The pair decided on a tropical theme and accumulated a variety of grass skirts, streamers, leis and cardboard signs.

    Mike posted several times on the practices’ Facebook and Instagram accounts, and John reached out to the local paper to ask a reporter to visit during the event. The front desk mentioned the event to everyone who called in, and a framed sign was placed at the check-in counter. In the week leading to the big day, the opticians noticed several patients opting to hold off on purchasing to take advantage of trunk show discounts.

    Friday morning the staff arrived in Hawaiian shirts, full of energy. The day flew by and soon it was 3 p.m. The office looked fantastic: the frame reps had plenty of space to spread out their trays, the food and drinks were beautifully displayed, and a dozen helium-filled balloons at the sidewalk swayed in the breeze. The team waited eagerly near the front door.

    At 3:15 p.m., a man with his two small children came in and went straight to the food table. Mike greeted them.

    “Oh, I’m your frame rep’s husband,” the man said, pointing towards the showroom. “We’re on our way to camp for the holiday weekend as soon as she’s done. Six o’clock, right?”

    “Right,” Mike replied feebly.

    A couple who had exams earlier in the week showed up to browse and enter the raffle, but by 5 p.m. it was just the staff and the reps.

    Eventually Dr. Fung cornered Mike and John. “Guys, what’s going on? Where are the people?” she asked.

    Just then a woman walked through the front door. “Hi, I’m a reporter with the Post Dispatch,” she said, greeting the group.

    John and Mike looked at each other weakly.

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    The Big Questions

    • What could John, Mike and the rest of the staff have done differently to attract more attendees?
    • Is there a way to salvage this event? How would you handle the reporter?
    • Should Dr. Fung, as the practice owner, have done something different? As owner, would you agree to another trunk show in the future?
    Sam M.
    Princeton, NJ

    Five weeks wasn’t enough time to prepare. You have to do mailings, email, social media etc. Did you do newspaper ads? Did the participating vendors help in marketing? I also wonder if there were too many brands shown. A trunk show should be something special. We do a Lafont Trunk show every year because it IS a special line. We sell 30-35 frames in a three-hour period. Also, don’t give up! Trunk shows build on themselves. Every year you will get more people coming in. Make it a yearly event.

    Anissa L.
    Berkeley, CA

    It’s so hard to put together an event such as a trunk show. So, kudos to the lead opticians for the excitement. There are a few things I would have changed. 1. It’s never a good idea to put an optical event directly before any holiday. At that time families are spending time and money together. Solution: It would have been smarter to put the event two weeks after Labor Day. That way there would have been a better turnout and any vacation money would have been put back in people’s bank accounts. 2. Advertise! Post! Retweet! Anything to get the word out. It seems like that wasn’t done to entice people to come into the office. Maybe they didn’t know it was happening. 3. Too much excitement. When an office isn’t known for a trunk show, wait until the third go to get maximum turnout. Next time’s the charm!

    Scott K.
    Dover, OH

    First: Never have a trunk show on a holiday weekend — too many people traveling. Second: Send postcard mailers to specific household income or net worth homes in the surrounding area. On one side of the postcard make it simple and eye catching. On the other side, give some details about the trunk show but keep it clean and easy to read. Third: If possible, email your top customers. Fourth: Have the sale the same weekend every year to build up awareness over time. Fifth: Run a large ad in the local paper — go big or go home.

    Judy C.
    Virginia Beach, VA

    1. Wrong day, wrong theme. Never schedule an event on a holiday weekend. Never. Tropical theme is great, but perhaps during cold weather when everyone is dreaming about their summer vacation. Have a Kid’s Day in early August or a Mom’s Day in the spring.
    2. Nothing to salvage. Divvy up the food among the staff and reps and call it a day. Use the time with the reporter to talk about eye health and lens/frame options.
    3. Start planning the next trunk show immediately. Choose a date and a theme and set a timeline for publicity. Build excitement beyond the practice. Invite the neighborhood!

    Lois S.
    Winter Park, FL

    I think they had the right idea, but needed to NOT have it on a holiday weekend, and hold it during the week, in the daytime or afternoon. Perhaps they could stay an hour later to accommodate people after work. I would have it on a busy doctor day, so your patients coming out of the exam room will purchase. If you have no more exam spaces available, write up the order, hold it in the computer, make an exam appointment, and offer them the special pricing then. Perhaps they could have contacted their best-purchasing patients by phone or postcard to inform them of the event.

    Jenna G.
    Fargo, ND

    First thing: BAD DATE/TIME. The Friday before a long holiday weekend is not a good time to try and get people to come shop. They want to get out of town. Why clear the schedule? Instead, use that time to target patients who want to buy glasses, have them come in for their exams, and have a bigger selection to choose from. Let them know there is going to be a party and you want them there! Use the reporter to talk about the practice, not just the event. Maybe they should sit down with the practice owner and talk about what is unique about the practice. Don’t send away free advertising! Unfortunately, you can never totally predict turnout. We have had trunk shows where I have done the exact same amount of marketing, and some are hits, and some are misses. Document and evaluate. Be brutally honest about what went well, and what didn’t. Learn from it, and do it differently the next time.

    Jon L.
    Madison, IN

    As the founder of McDonald’s would say, “Early to bed, early to rise, advertise, advertise, advertise.” Ray Kroc knew that if you want business, you have to let everyone know what you are all about. Don’t think that happened here.

    Alicia M.
    Anchorage, AK

    Their first and biggest mistake was the timing of the show — Friday afternoon on Labor Day weekend. The only thing folks want to do is get off work early and finish loading up the camping and boating stuff, and leave for the weekend. Not go visit their eye doc’s office. I think if they had picked another day, possibly a Tuesday or Wednesday afternoon not preceding a holiday weekend, they would have done better.

    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.

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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.

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