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Real Deal

A New Owner OD Needs to Navigate the Bartering Culture in His New Community

“I plow your driveway when it snows; you serve my family’s eye needs.”

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ANDREW RICE, a Maryland native and new grad, had recently purchased a retiring optometrist’s practice. He and his wife fell in love with rural northern Minnesota at the second meeting with then-owner Roland Dibbs. While this was a big decision, there was something about Roland that put Andrew at ease. 

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
  • During his first month of ownership Andrew closed the office and performed major renovations. In addition to updating the floors and painting the walls, he raised the ceilings and removed walls to make the space more modern. 

    The practice finally re-opened and Andrew was able to meet Roland’s patients, who all seemed to also be Roland’s friends and neighbors. Andrew was initially enthused, as he imagined that soon they would also be his friends and neighbors. Then he realized how this may impact his business.

    “Fitting your son to contact lenses will be $175,” explained Andrew to one patient’s parents, seated in the exam room. “The annual cost for lenses can be around $400, give or take. Once I fit him this year, future annual contact lens visits will be well under $100.”

    “Well, that’s all right,” said the father, “I plow the lane to Roland’s farmhouse in the winter so that more or less covers it.”

    It took Andrew a minute to understand what one fact had to do with the other. “Roland did retire last month, and I’ve purchased the office,” Andrew explained.

    “But this is still his place,” the father said with confidence. “I mean, the name is the same, the staff are all the same.” 

    “I have purchased the business from Roland,” Andrew reassured him.  The man looked at his wife and furrowed his brow. “Okay,” he said slowly. “Well, we don’t have insurance, and we weren’t expecting to pay.” 

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    The entire family was looking at Andrew, waiting for him to solve the awkward issue at hand. Not one for confrontation, Andrew quickly blurted, “Having a reliable person to plow sounds great!”

    That evening Andrew’s wife Ginny took him to dinner to celebrate his first day. The day’s strange interactions were a hot topic. 

    “Roland’s sister-in-law dropped in to talk to the optician and asked her to find out if her family would still be allowed to buy glasses at cost,” Andrew said. “The plow service actually sounds pretty great, but the guy has four kids and we’re talking about at least a few thousand in services and materials!”

    Ginny sighed. “The remodel put us into debt, Andrew. As our bookkeeper, this isn’t in our best interest. I’d rather buy a snow blower for $400 and do our tiny driveway myself, if it means we can put that family’s payment toward our debt.”

    “Fair point. The receptionist told me Roland’s barber is on the schedule for tomorrow,” he chuckled, rubbing his shaved head. 

    “I’m going to text Roland right now,” said Ginny, grabbing her phone. She spoke aloud as she typed: “‘You sure had lots of barter deals with patients. Not sure we can honor. What are your thoughts?’” Almost immediately, Roland replied: “Your business, your choice.” 

    “Thanks for the help, Roland,” Andrew said sarcastically. 

    “Oh man,” groaned Ginny, “What if these deals are a major component of the business? What if the community turns against us?” 

     

    The Big Questions

    • Should Roland have divulged the extent of his practice’s bartering?
    • If bartering is the accepted culture, should Andrew adapt or run the business his way?
    • How can Andrew explain his new policy?
     

    Expanded Real Deal Responses

    Mona D. Fort Wayne, IN

    1. Yes, the trade agreements should have been divulged.
    2. Bartering is not in Andrew’s best interest. With a new practice loan and renovation costs, he is cash-poor. The barter expected is not just for his service but for goods. Andrew will have lab bills and frame costs out-of-pocket to accept barter trades he doesn’t even need or want. This will be a cash flow disaster. It is better to have the patients leave which creates no cash flow rather than to barter and have a negative cash flow.
    3. Andrew should ask Roland to provide a list of all individuals with whom he had a barter agreement. Further, he should request that Roland send each individual a letter explaining that Andrew is the new practice owner and that he will not honor old barter agreements. This letter should be approved by Andrew. If the staff know a barter agreement existed, they should politely quote Andrew’s usual examination fees when an appointment is scheduled. Then there is no surprise after services are rendered.

    Jen H. Sandpoint, ID

    1. Roland probably wasn’t being intentionally misleading. Selling a practice is hectic and stressful. Andrew and Ginny should give him some slack for the oversight, if they truly are embracing the small-town experience. 
    2. We do trade-of-service, but we don’t accept every offer or inquiry. Andrew should adapt as seems viable. Maybe he can offer to trade services with the snowplow guy’s family for 1-2 kids, and then insist on payment for the remainder. Since only one son has been seen so far, they have time and opportunity to barter out the rest of the family. Also, it might be good for Ginny to participate in future barter conversations with patients. Andrew can provide the warmth, and Ginny can provide the tactful backbone. Patients usually appreciate knowing the honest struggles of optometrists as fellow business owners, because it opens the door to genuine relationship.  
    3. Andrew’s front staff should ask each patient about their intended method of payment as part of the scheduling process, which will allow the chance for renegotiations prior to appointment.

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    Leisa S. Newport Beach, CA

    How about trying a different approach? Have an open house party with trunk show which would allow the community to meet the new doctor. There is a huge difference between the philosophy of the older generation OD’s and the fairly recent graduates. Just wait you might only be scratching the surface of treatment philosophy and contact lens evaluation etc. Barter can get out of control quickly, and no matter how you end, you will never be able to please everybody. After all you are a different doctor so change is automatic. Perhaps until established, postpone doing any barters until your feet are on the ground. At least then you are maintaining the same status for all your patients not hand-picking which barter you accept.
    If there are other practices in the community, obviously creating an immediate distinction between the retired doctor and the new doctor, and hopefully creating excitement in new philosophy, frame styles and product would probably help.

    Chani M.  Highland Park, NJ

    When I bought my practice in 2015, I was faced with a similar situation — every other patient expected the same outrageous discount they had been receiving for the last twenty years. In this case, yes, the seller should have revealed the extent and nature of the barter system. I think if Andrew keeps going with this barter system he will lose money, but will he lose patients? If he loses patients that are not paying him, he’s not losing anything at all. If he is the only practice in the area, patients will have to get used to his new policies. He may want to structure the fees attractively for the non-insured (without doing anything non-kosher). Each situation is an individual case and he may need to address each one as it comes up rather than making a blanket decision. He also should make prominent signage in the front stating the new policies in a friendly way. This may take years to resolve… trust me, I know.

    Pam P. Downers Grove, IL

    Roland probably should have been up front about the bartering, wouldn’t his books have shown this activity? Possibly Andrew could accept the barter for the first year and outline what would occur after, requesting invoice to invoice follow up to make sure he was getting fair deal? Also, would have to change the terms so that the former owner was not reaping the benefits. Right away, a letter to any remaining patients not seen in the office explaining the transfer of ownership and what new policies would be would be appropriate. Andrew may need to set up meetings with some of the patients before seeing them to work out any barters, discounts or new policies going forward.

    Jamie L. Bradenton, FL

    He should put a sign in the reception area welcoming new patients and introducing his pricing policies. He could put a sentence or two that thanks the previous owner for his long-time relationship with his patients and that he looks forward to making new relationships with these same patients. He should be open to the idea of bartering, but only if it is a fair trade for both parties. If his staff has access to patient’s previous exam charges (or lack of) ahead of time, a phone call to the patient explaining that the patient should be prepared to pay would be prudent.

    Ann H. Sturgeon Bay, WI

    Absolutely stop the bartering. Andrew needs to prove to the existing patients what a great doctor he is and the rest will fall into place. He should have his office manager tell them his accountant won’t allow him to barter. He should support his community outside of work by going to high school sporting events and showing his patients he cares about their families. Support as many fundraisers as he can afford. That will mean a lot and his patients will love him for his generosity. He and his wife have bills to pay! This is now his business, not Dr. Roland’s, and the community will adapt to his rules.

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    Rick R. Girard, PA

    1. I don’t think Roland had any obligation to divulge that information, but it would have been nice to have a heads up. Didn’t Andrew take a look at the books before he bought the place? “Why don’t you have any profit, Roland?” “I barter for everything.”
    2. I suppose he could adapt to a certain point but he’s going to have to run things the way he wants or go out of business.
    3. That’s something that has to be explained before the exam even begins.

    Robert M. Edina, MN

    Yes, Roland should have highlighted the extent of his side deals. I would have thought He would have followed Roland for a few weeks in the practice and much of this would have come to light. Andrew should think about the bartering aspect and get some professional advice as there could be tax consequences, as well as Medicare issues, with trading services. He needs to take Roland to lunch and find out how pervasive the bartering thing is. If it is small, I would use what worked for me and explain to those whose barter did not meet my needs we would be able to offer them a cash discount instead on products. Should it be a large part of the practice, he will need to explain to his patients that he has researched bartering and found that these transactions must be reported as taxable income. The simple truth is that if done legally it is more trouble than it is worth.

    Nikki G. Oakdale MN

    Roland SHOULD have been up front about his bartering services. However, if you purchase an existing practice and the claimed income on the financial statement were the basis of your decision, then you would have also planned your spending around only those funds. So, the barter services should then become irrelevant to your expected income. Going forward with a new awareness, Andrew could offer those people a payment plan, understanding there will be some period of transition, and those patients should have NEVER gotten so far as the exam room without having payment arrangements in place. Therefore, to avoid this conversation in the future, the entire front office staff should be trained on the policy for handling past barter patients and that dialogue should be consistently carried from the front desk, to the exam room and on to the dispensary.

    Jennifer L. Dansville, NY

    If you have a service that you can trade for someone else’s’ by all means barter dollar for dollar. It’s certainly a way to connect with people. Always say, “This is a deal between us exclusively,” so they aren’t telling everyone. I’m pretty certain that you won’t be able to duplicate the barters your previous owner had but assess each offer and explain why you will or cannot accommodate their request. Be respectful of their offer. If Andrew is not comfortable bartering then telling his patients he’s been advised by the IRS not to participate in bartering should be enough to scare anyone. In small communities, it’s pretty common. You need new sunglasses and I need a tree cut down…Your son needs glasses and I need to rent a tent from your company….I’ll knock $25 bucks off today if you plow the parking lot after the snow we’re getting tonight…

    Michael D.  Eldersburg, MD

    1. Yes, ethically Roland should have let Andrew know. Shame on Andrew’s lawyers/accountants for missing that.
    2. He should have a discussion with other professionals in the area and see if this is the custom or isolated to Roland. Change the name of the business so patients know they are dealing with a new entity. Perhaps a letter from Roland to the patients explaining new ownership and how great Andrew is.

     

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    Real Deal

    A Patient Pushes an Optician to Bend the Rules. Is This A Gray Area Or Are They Committing Fraud?

    The case of the fraudulent filing

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    COLIN WAS STRESSED. His coworker had called out an hour before her shift, leaving him to run the optical floor solo. Two patients were already moving through the frame boards when a tech escorted Dr. Tam out of an exam room and over to Colin.

    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

    Dr. Tam was a local general practitioner. Colin was relatively new to the Utah practice but he had already met Dr. Tam during his son’s eye exam.

    “Nice to see you again,” said Colin, pumping the doctor’s hand. “Did your prescription change?”

    “My reading power is being bumped up,” said Dr. Tam amicably. “I’ll get new progressives; you have my insurance information?”

    “I do! I’m working with a few other people, but I’ll do my best to get you out of here quickly,” promised Colin. “I’ve got five frames pulled for you to start, see what you think and I’ll be right back.” After checking in with the first two patients, Colin bounded over to the reception station and pulled benefit printouts from Dr. Tam’s chart. When he came back Dr. Tam was already seated at an optical station.

    “I like these,” he said, clasping one of the pairs Colin had selected, “and I want to order these Maui Jim sunglasses under my son Richard’s insurance plan. Do you remember him? He was in last month.”

    Colin sat across from Dr. Tam and used a nearby laptop to look up the boy’s information. “It looks like he wasn’t given a prescription at his exam. Your insurance plan has a minimum prescription requirement to pay for the sunglasses,” Colin explained.

    “Oh, that’s right,” said Dr. Tam, reaching into his breast pocket. He pulled out a prescription pad and, in front of Colin, wrote out a prescription for his son. “It needs to be a half-diopter, right?”

    Colin nodded numbly, and awkwardly took the script when Dr. Tam handed it to him. “I need to take his measurements…”

    “Just use what you have from last year,” said Dr. Tam. “It’s tough to get him in, between everyone’s busy schedules.” Sure enough, Colin found an entry in the EHR for another pair of Maui Jim sunglasses. Colin priced out the orders, took measurements and escorted Dr. Tam to reception to collect his copays.

    Later that afternoon Colin found time to enter Dr. Tam’s orders. However, when he entered the authorization number that the front desk had pulled he found it was actually for Dr. Tam’s son – Richard Tam Jr. Dr. Tam’s benefit wasn’t available until the first of next month.

    Colin immediately called the number on file for Dr. Tam. His wife answered their home’s landline and Colin explained the situation. “I can hold the order for three weeks and then process the exact day his benefit resets?” Colin offered.
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    “No, no,” said Mrs. Tam. “He’s been complaining for weeks, I don’t want to delay. I’ll just give you my credit card.”

    Colin rushed the two orders but it was weeks before Dr. Tam finally came back for his dispense.

    “Oh, these are great!” said Dr. Tam enthusiastically, studying the near vision card with his new progressives.

    Colin beamed. “Did you bring your son? I was going to adjust his sunglasses for him.”
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    Dr. Tam chuckled. “Well, they’re really for me,” he shared. “Of course I’ll share them with him if he wants, but I need them when I’m wearing my contact lenses, and I lost last year’s pair.”

    “Ah,” Colin nodded. “And I assume your wife told you she ended up paying for your glasses since you weren’t eligible?”

    “Yes, it reset this past Monday, right?” asked Dr. Tam. “Just give me the invoice with Monday’s date and I’ll submit it.”

    “I don’t think we’re allowed to change the date,” said Colin. “Technically the insurance company considers that fraud.”

    Dr. Tam scoffed. “If anyone gives you a hard time, you just have them call me,” he replied.

    The Big Questions

    • If you were Colin, would you have done anything differently when discovering Dr. Tam’s eligibility was incorrect?
    • Assuming Colin is physically able to revise the EHR to date the order to the first of the month, should he provide the invoice for Dr. Tam to submit his claim?
    • Would you dispense the sunglasses, or return them, accept the loss, and report Dr. Tam for fraud?

     

    Maureen G. Oak Park, IL

    Didn’t Colin look at the name on the benefit sheet?! And seriously who would order anything based on a script a patient wrote out? I would have said, “I am sorry I need a valid doctor Rx, otherwise it’s not valid and I can lose my job over it.” We always have the sheet printed out with the patient’s name and benefits eligible highlighted. Colin sounds like a pushover; we have had patients who want to use their frame benefit for plano sunglasses and our answer is always, “No, that’s committing fraud.” I can’t believe any ethical optometrist would endanger his practice by agreeing to do this.

    Rigo L. Indio, CA

    Let me start by saying we all “bend” the rules from time to time for some of our “VIP” patients. That being said there is a line to draw when bending the rules becomes fraud or feels wrong. As opticians we feel that any professional that walks into our office will always do the right thing. So when doctor Tam wrote an Rx for his son I would have told him that I didn’t feel comfortable filling the Rx, even though I knew what he was doing, and that I would rather talk it over with our doctor. At this point he would have to understand that something smelled fishy. When he asked to change the date, I would be frank with him and just say that I would not feel right doing that. If you bend the rules one time the patient expects the same the following year. Sometimes it’s just best not to do things, no matter who the patient is.

    Peter N. Belfast, ME

    This case is not uncommon. The simple answer to somebody who asks you to lie to the insurance company is: “Do you want me to lie to you?” The answer is usually, “No.” Then you can say, “I’m not going to lie to your insurance company either.”

    Lynn M. Fallston, MD

    1) I would have done the exact same thing with the eligibility date. If the patient’s wife chose to pay I would take payment and proceed with the order.
    2) I would NOT change the date in our EHR to facilitate insurance fraud. Not happening!!
    3) I wouldn’t dispense the glasses…BUT it never would’ve gotten that far because….I never would’ve taken the Rx from a GP to begin with. Is that even legal??

    Preet K. New York, NY

    I’d explain to Dr. Tam that the practice can get audited at any given time, and this is considered insurance fraud. I would offer a discount on a second pair. Colin should not have accepted the Rx written by Dr. Tam as it is an unethical action taken by Dr. Tam. If the doctor who examined Tam Jr. didn’t prescribe any Rx, Colin should follow that. Ask Dr. Tam to reach out to the insurance to find his options to process the sunglasses order or offer to make the phone call on Dr. Tam’s behalf. (This shows customer service.) If Dr. Tam is uncooperative, call the insurance and inform them about Dr. Tam writing the Rx for Tam Jr. Colin shouldn’t change the DOS for the private-pay order even if the EHR system gives him the ability to. Have the patient discuss this with his insurance as well. I wouldn’t recommend processing the sunglasses order unless Dr. Tam follows the right steps. Document everything. Have Dr. Tam sign a liability form, which protects the practice from auditing.
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    Kate G. Arlington, VA

    Fraud is fraud. Why sully your reputation?

    Amelia B. Charleston, SC

    Insurance fraud is any act committed to defraud an insurance process. This occurs when a claimant attempts to obtain some benefit or advantage they are not entitled to, or when an insurer knowingly denies some benefit that is due.

    Theresa W. Austin, TX

    Graciously, the optician should have advised the patient that the prescribing physician had not provided a script for his son, so unfortunately the sunglasses would not be covered by insurance. The optician then should ask, “How do you wish to proceed?” There can never be an exception for fraud.

    Daniel M. Rockaway, NY

    Of course he should not do any of those things. It is considered fraud and he risks at least his participation in the plan if not the license of the practitioner itself.

    Genna L. Milwaukee, WI

    Colin did the right thing by attempting to contact Dr. Tam. However, it’s important to speak directly with the patient when they’re responsible for their own care. Speaking with Dr. Tam would’ve given Colin an opportunity to assertively avoid possible fraud and any consequences of it. It would’ve been 100 percent wrong for Colin to modify the invoice date to comply with Dr. Tam’s request. Had the claim been audited, the insurance company would’ve found evidence of fraud in everything from the copay dates to material order dates. Dr. Tam, as a medical practitioner, is required to acknowledge that he understands insurance fraud and its consequences, and as such he should not be instructing other health care providers to commit fraud on his behalf. Were I in Colin’s situation, I would suspect Dr. Tam of committing fraud at his own practice, and would absolutely report Dr. Tam and accept a loss on the materials I ordered, knowing that I did the right thing.

    Judy C. Virginia Beach, VA

    1) Colin did the right thing by calling immediately when the issue arose.
    2) NO! Changing dates on a receipt or in patient records is fraud. This is not a “gray area” in my opinion. Unless the offending doctor owns the insurance company, he doesn’t have any clout with them either.
    3) Dispense the eyewear and note the conversation in his record. I would also make the practice owner aware of what his patient requested and that he stated that it was done for him in the past at the practice. Let the doctors discuss the issue. Neither Colin nor any other staff members should have to be caught in the middle of this.

    Stewart G. San Francisco, CA

    1) NO
    2) NO
    3) I would make him pay for them—nothing more, nothing less. If he refused, I’d send him to collection, AND I’d dismiss him as a patient.

    Taylor K. Ellington, CT

    1) Colin handled the situation appropriately when he discovered the eligibility issue—he called the patient immediately. HOWEVER, the first issue really arose when the patient wrote his own prescription. We would not have filled the Rx, as it was not valid. Regardless, Colin should have accepted the wife’s credit card for the full charge amount without insurance and continued with the job.
    2) I would assume most systems, like ours, allow for date change on the invoice. However, of course, this is fraud and Colin should not do this.
    3) I would have dispensed the sunglasses, as they should have already been paid for in full by the wife. I would advise Dr. Tam he can do what he wishes with the invoices, but that the office cannot and will not change any posting dates as it is fraud.

    Bob S. St. Louis, MO

    I wonder if Dr. Tam is as loose with insurance policy in his office as he expects Colin to be. While technically he did nothing illegal by writing an Rx for his son, it was an ethically reprehensible thing for a healthcare professional to do. Even worse, he expected Colin to risk his job and the reputation of his company by performing an illegal act. Again, I wonder if it is a standard operating procedure to falsify records in HIS office. If I remember nothing else from optometry school, one thing will be forever ingrained in my mind: “Never change a record. Put a line through the original information, insert the correction, initial and date it.” It’s a digital world now but the advice is still as relevant as in the good old (paper) days.

    Leisa L. Newport Beach, CA

    Dr. Tam’s eligibility should have been checked before the order was taken for his new glasses. However, since Colin notified Dr. Tam indirectly through his wife the order became a private order and was paid accordingly. The receipt date should not be changed to appease Dr. Tam. In regard to dispensing the Maui Jim sunglasses, Colin submitted the order with the proper Rx information provided for Dr. Tam’s son Richard with the required measurements from Richard’s chart. Technically it should be said that Richard is sharing the glasses with his father, not the other way around. This is one of those areas that is stretching the system by Dr. Tam; Colin was following the Rx provided by Dr. Tam for his son.

    Judith W. Orange, CA

    No, we do not change invoice dates; that is fraud plain and simple and no patient is worth the legal problems. As far as notifying the patient of his options of waiting till the first of the month or paying for the glasses, that is our standard policy. As far as making glasses without having a proper written prescription—either our own (from records) or from another OD or OMD—we would not do it. We do not feel that a primary MD can give a complete comprehensive eye exam, especially if he is just writing out what is necessary for insurance coverage

    Jennifer Torrance, CA

    I would have discussed all this with management first to see what options they wanted me to proceed with. If those options comprised my morals or ethics, I would then proceed to remind management that we have an obligation to not just the patients but to the practice and employees to make sure we have a secure livelihood by following the rules. If we continue to bend the rules, we will go down a path of no return and will be held hostage by patients that know we shouldn’t be doing this.

    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

    A Difficult Teenager, Absent Parents and Unacceptable Behavior … Kick the Kid Out or No?

    This office wants to show a pre-teen the door – should mitigating circumstances change their minds?

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    IT WAS LATE MORNING and patient care was in full swing at a large optometry practice in Detroit. Doctors and technicians hustled patients between rooms, and the phone rang incessantly.

    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

    Technician Carol headed to reception to call in the next patient, 15-year-old Jennie. “Do you have a parent with you?” asked Carol, scanning the room. “My dad dropped me off,” she replied flatly. “It’s fine.” Carol shrugged and led Jennie to pretest. She began reciting her script of instructions, but Jennie threw her off quickly. “Is this the puff of air?” she asked dramatically. “No,” said Carol, “like I just said, it’s an auto refractor, it’s just a picture. Nothing is going to touch you.” Jennie was clearly skeptical, and kept pulling her head away from the forehead rest. Carol worked hard to convince Jennie to keep her head still, but only captured one good reading in each eye. She didn’t bother asking Jennie to use the non-contact tonometer, and escorted her straight to an exam room. That’s when Carol’s challenges really began.

    Jennie refused to disclose her health history or medications, left the room twice to use the restroom, and repeatedly challenged Carol’s competency. Twenty-five minutes later Carol still hadn’t completed Jennie’s work-up. Saying she needed something from another room, Carol found a quiet place down the hall and took a minute to collect herself. When she returned, she immediately noticed the 90D and 20D lenses were missing from their regular places. She wrapped up the exam and found office manager Ed. “I think my patient is trying to steal from the exam room,” she whispered. Ed frowned and followed her into the exam room. “Hi Jennie, I’m Ed the manager,” he said, standing in the doorway. “Can you please check your pockets and backpack for anything that might belong to our doctors?” Jennie scoffed, her neck and arms erupting in hives. Time seemed to stand still. “Screw you!” she eventually yelled at Carol, who threw her arms up in exasperation. The exchange drew Dr. Cox out of her exam room. “What’s going on?” she asked Ed. As she neared, something hard struck the back of her hand. She yelped in pain as a 90D lens hit the floor then rolled fast along the baseboard. Dr. Cox looked up to see Jennie palming the 20D, a look of shock on her face. “I didn’t mean to hit you!” she said, clearly scowling at Carol. Panicking, she dropped the lens and grabbed her coat. “Move,” she said, and Ed finally cleared the doorway. Jennie flew around the corner and out the front door.

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    Dr. Cox motioned Ed and Carol into the empty room and closed the door. First Carol, then Ed recounted the last half hour’s events, concluding with the same thought: “We have to fire her from the practice!”  Dr. Cox, gingerly massaging her hand, raised her eyes to the ceiling. “Jennie’s mom is my husbands’ boss,” she said slowly. “I am going to make a call after I get back on schedule, and we will figure this out.”

    Hours later, Dr. Cox’s cell phone received a voicemail from Jennie’s mother. She explained how Jennie’s behavior over the last few months had been worrisome, and they were receiving assistance from a psychologist in addition to the pediatrician. She begged Dr. Cox to let Jennie return the next day to complete her exam, and promised to attend with her daughter.

    The Big Questions

    • What considerations should a practice have when dismissing someone under 18 years old?
    • If Dr. Cox decides to allow Jennie back, the staff won’t be pleased. Is there a way to mitigate this?
    • At what point did Jennie cross the line, based on your office’s culture? Would you allow her to return?

    Expanded Real Deal Responses

    Judy C. Virginia Beach, VA

    The first problem was allowing an underage child to be seen without a parent or guardian in attendance. That’s should never be allowed. Additionally, I don’t see dismissing an underage patient without a consultation with the responsible adults. The staff may not be pleased, but that should not affect their professional performance. If it does, there is a bigger problem to be addressed. Jennie crossed the line when she refused to participate in the pre-test workup and she should only be allowed to return with a parent or guardian.

    Stewart G. San Francisco, CA

    Why was this patient seen without a legal aged family member? The patient should have been kept in the waiting room until the adult relation arrived and could be present during testing. This child is a thief. She could have also declared that the staff touched her inappropriately causing a lawsuit and a ruined career.

    Dennis I. Monroe, CT

    Our office is very specific towards seeing unaccompanied minors. NO! If it is a new patient; definitely not! If a new patient’s parent insists, then we discuss the nature of liability in these situations. That usually ends with the parent making the appointment when they are available. If it’s a patient that the office is familiar with, there may be exceptions, but the answer is most often if not always: NO. There is too much that we as physicians are responsible for and parents need to be… Parents. There is too much at stake to see an unaccompanied minor.

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    Donna R. Mission, BC, Canada

    I once had a patient threaten to punch me when I did the NCT on her. She yelled at me loud enough for the doctor to come out. She quickly tried apologizing and said I scared her. He opened the door to the office and said he would happily send her file to any other doctor she wanted. If you know your child is having issues then you make arrangements to accompany them to appointments. There is no excuse for theft. As for the husband’s boss connection, that’s an employee standards issues if they take it out on you.

    Kinga B. St.Catharines, ON, Canada

    Really the issue here is that she has behavioral issues, and I don’t think they would magically go away at 18, only the legal issues change. There should be a policy that minors of any age can be seen alone provided they can BEHAVE like an adult. The conversation should be had with the person booking the appointment at the time of the appointment and if not, then at the time of the reminder call. Perhaps an email of expected behavior could be sent to the parent or student, or simply stated that any behavior not allowed at school is also not allowed at the optometrist’s office. And it should outline the concentration they are expected to have so the exam can proceed. There should be an open door or 3rd party policy to prevent the allegations of sexual abuse also. The first time any child or teen shows up there could be a behavior agreement they have to sign. Most kids are fine but with the high rates of autism/Asperger’s and general behavioral issues, and the large number of frazzled parents who can’t take the time to accompany their kids, there has to be a line in the sand and the office needs to set expectations.

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    Erin J. (From Facebook)

    Bye, Jennie! The lip I could look past, and would let her come back with a parent at our earliest opening (usually about two weeks out). However… the thieving and assault on my staff? No. That behavior would get you banned from any business, and possibly charged. My business is no exception.

    Rick R. Girard, PA

    1. Why would the parents let her come alone knowing she had problems? There is a parental issue to deal with. 2. It’s Dr. Cox’s office so I don’t think the staff should be upset. If they are that’s another issue. It’s not like Jennie threatened violence. 3. She crossed the line by stealing. Whether she can return should be based on all available info and Dr. Cox’s decision. Because I sometimes stupidly believe the best in people, I would allow her to return.

    Dr. Texas S. Citrus Heights, California

    No minor should be examined without another adult present—ever! I would do the pre-screen myself on the next visit. During the exam I’d show her what bio lenses are for. I’d dilate her mom, put the bio on Jennie and have her look into her mom’s eye. I’d ask Jennie if she had questions and be sure she leaves with pens, a makeup mirror, and eyeball keychain, but not my bio lenses or lens clock (I’ve lost three in 50 years). If Jennie needs an Rx, have your most tech-savvy optician take pictures during frame selection. If she balks at these, drop it.

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    Real Deal

    Optician Wants to Ignore Part of Prescription — but Is That Her Right?

    The doctor prescribed it for the customer; the optician said he’d hate it. Who wins?

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    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
  • KATE, AN OPTICIAN, and Mark, an optometrist, were partners with a practice in a trendy hamlet outside Atlanta. Mark’s undergrad college roommate Derek recently moved to town and he was invited in to see the office.

    “Kate, this is Derek,” said Mark. “He was interested in looking at glasses.”

    Derek grabbed Kate’s hand and pumped it enthusiastically. “I had an eye exam just before losing my coverage back in Texas but I held off on getting glasses because it usually takes me a few tries before they work,” he explained. “I have the prescription here,” he said, fumbling for his wallet.

    “Kate’s the best!” Mark gushed, playfully punching her in the bicep before grabbing his friends’ shoulders. “Let’s find you an awesome frame.”

    “What is your occupation, Derek?” asked Kate, unfolding the script.

    “I’m in marketing and advertising,” he replied.

    “He’s being modest, Kate,” said Mark. “He owns his own firm.” Mark leaned over and whispered: “He’ll be a great referral source for us!” Kate nodded her understanding, then stepped back as a tech came to retrieve Mark for his next patient. The two friends gave their goodbyes and Kate invited Derek to sit at the dispensing desk.

    Kate smoothed out the prescription on the table to examine it. “So, Derek, have you worn progressive lenses before?” she asked.

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    “I don’t think so, I just have these,” he said, pulling his glasses off his face and handing them to her. She examined them quickly—single vision. “They’re about four years old,” he continued. “I know I’ve needed to update them for a while.”

    “And are you having any double vision when you read?” she asked.

    “Double vision? No, I don’t think so,” he said. “I just don’t want to keep taking my glasses on and off. It makes me feel like an old man!”

    At the end of the day, Mark joined Kate in the optical lab to review Derek’s order.

    “The prescribing doctor made a note to include slab off,” Kate began. “It’s his first progressive; never had slab off. I want to make this without and see how he does.”

    Mark arched an eyebrow. “This doc in Texas prescribed slab off. You’d consider ignoring it?”

    “Of course,” replied Kate. “It’s not a part of the prescription; it’s a suggestion. I’m the optician, so I have to do what I think will work.”

    “Okay,” said Mark, “but why not call the doc and just ask?”

    “It doesn’t matter what they say, I don’t want to give this guy slab-off until I know a regular progressive won’t work,” insisted Kate.

    “What if I want to?” Mark shot back.

    “Are you going to dispense and do all the follow-up work when he hates them?” said Kate.

    The Big Questions

    • Who has the final say on using slab off—the prescribing doctor or the dispensing optician?
    • If Kate gets her way, is she obligated to disclose to Derek that she’s not following the prescribing doctor’s instructions?
    • If Mark wins the debate and the patient can’t adapt to slab off, should the additional expense be waived?
     
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    Expanded Real Deal Responses

    Ellie V.

    Janesville, WI

    1. The prescribing doctor has the final say on using slab off. If the optician went without it and the patient went back to the doctor for a re-check and finds out it wasn’t put on, the optician will have to answer to the doctor!
    2. Kate is obligated to disclose to Derek they are business partners, and not following the prescribed Rx could potentially be a liability if the patient has an accident or problems.
    3. Yes, the additional expense should be waived; it’s part of business to take care of the patients.

    Darrell L.

    Goodlettsville, TN

    While the slab off will address the vertical imbalance, there is no correction for anisometropia. Correcting image size with base curves will address both image size and vertical imbalance. Calling the prescribing doctor and requesting no slab off with base curve changes would be the correct way to address this patient’s problem. The optician is financially responsible for remakes and therefore should be allowed to do whatever it takes to correct the patient’s problem, yet consulting with the prescribing doctor will keep all parties involved happy.

    Annette P.

    Allen Park, MI

    She needs to make it to the doctor’s specific Rx or call the prescribing doctor before making. She doesn’t know the conversation in the exam room and the specific tests the prescribing doctor did to come up with that Rx.

    Howard C.

    Ferndale, MI

    Before making the new Rx I would first have Derek put on his glasses, have him tilt his head back and look through the bottom of his glasses at a near target letter and ask if he noticed any vertical diplopia. In addition, I would set up the new near Rx in a trial frame and do the same thing. If he notices any vertical double vision in either test, slab off is needed. If he does not, no slab off is needed. Taking the few minutes needed to do these tests would be worthwhile, providing a definitive answer and greatly reducing the need for a remake. The doctor should do the tests; he is the person to have the final say.

    Caitlin W.

    Montrose, CO

    I think it is a lens attribute — therefore it would be an optician decision. If the lenses are not working, generally labs will give you 60 days to make changes without charging the full lens amount again.

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    Micki L.

    Juno Beach, FL

    Call the prescribing doctor. If it was written on the Rx it is prescribed.

    Sugako A.

    Saint Louis, MO

    No slab off — try it as a regular progressive. If it doesn’t work, remake with slab off.

    Richard K.

    Lone Tree, CO

    In our practice, we take the view that when a patient moves/crosses state lines, that he now becomes our responsibility whether or not he is using our prescription or an out-of-state prescription. As “partners,” there should already be an understanding between Mark and Kate for issues like these before they crop up. As for the slab off, I don’t like to do them on PALs. It’s not that it won’t work, I just hate to put a line on a line-less product. Instead, I have my lab eliminate some of the equalizing prism on one lens to reduce the amount of vertical imbalance. Even though it doesn’t eliminate all the imbalance, it reduces it enough to keep the patient from experiencing double vision. In our state, it is considered a recommendation and I would not tell the patient one way or the other. It’s an easy calculation for the lab to do.

    Christopher B.

    Bergenfield, NJ

    With progressives, the bigger concern than a prism imbalance at near is image size differential. I would not slab a progressive unless I had a complaint from the client that they were getting diplopia at near in their progressive. The average person can adapt to a considerable prism imbalance. I would however choose the base curve and thickness so that image sizes between both lenses were closer to agreement. The optician is the final say on how the lens is manufactured. The doctor can suggest a certain brand of progressive, but it’s up to the optician and the client to decide which is best for them. I would explain to the client what slab off is, and that in this case I would not recommend that option, but if he experiences double vision when reading we may have to remake the lenses. This would be covered under most labs’ one-time remake policy, so I would waive any fees and not pass them on to the client.

    Peter N.

    Belfast, ME

    The optician should confer with the prescribing doctor to determine the purpose of the prescribed slab-off prism. If they concur that the prism may not be necessary, then the optician could try that route.
    If Kate gets her way, she should definitely divulge that information to the patient to keep him informed. This will also avoid having to backtrack.
    If Mark wins the debate and the slab-off prism is necessary, the extra fee should be waived. This person could bring many referrals to the business.

    Chani M.

    Highland Park, NJ

    First off, I would never outright ignore any element of a prescription written down on that legal piece of paper signed by the prescribing doctor. I would make a phone call to the prescribing doctor to discuss the slab off and see what his/her thought processes were when the slab off was prescribed. Depending on what transpires, I would always discuss with the patient the situation and explain that Dr. X prescribed “slab off” because he/she thinks it is best for said patient, and if it does not work we will re-evaluate the need for slab off with the patient and the prescribing doctor. Usually the lab will comp one redo, so that should not be an issue. It is important to be transparent when dealing with patients/consumers! Not disclosing information to patients can bite you in the butt.

    Rick R.

    Girard, PA

    Since they are partners there should be some dialogue about the slab off, but Kate should have the final say. After all, opticians deal with the aftereffects, not the doctors. And if Derek has dealt with this difference in Rx all his life, then going without the slab off is the right call.
    She definitely needs to be upfront about the decision, but should offer a full explanation as to why she made it in the first place.
    Waived or refunded? We require payment up front, so it wouldn’t be waived. If Derek wanted to try the slab off, and it didn’t work, I’d explain we’d remake the lenses at no charge.

    David Gilman

    Rutland, VT

    Call the doctor and tell him your view, and see what he says.
    Yes,if you tell the patient up front what you are doing to save him some money and it fails, then the do-over should only be the cost of the slab off and not the rest of the job.

    Stewart G.

    San Francisco, CA

    The doctor has the final say. The optician is incorrect; the instructions are part of the prescription, just as an OMD would write how often to take a medication.
    I would think so, because if it doesn’t work out without, and she has to put it in later, the patient may find out the prescription wasn’t followed and that’s a death knell for the practice.
    Why not call the doctor who gave the Rx and discuss the matter? Did he absolutely want slab off, or is that just a suggestion? This way, the optician can explain what the complexity with a multifocal is and what they MAY need to do for the format to work.

    Jennifer L.

    Dansville, NY

    Any experienced optician will question a doctor’s Rx, whether it be a huge change in cylinder, missing prism, or slab off suggestion. The slab off here was a suggestion and it sounds like Kate has enough experience to know that it probably isn’t warranted. I don’t think it’s necessary to inform the patient—it may be more confusing than informative. A redo isn’t going to happen—I’m confident with Kate’s judgment.

    Daniel M.

    Rockaway, NY

    If it is on the prescription it should be filled as written.

    Martha D.

    Wheatfield, IN

    If an optometrist orders a slab off you should make it according to the script. At least she should call the doctor and talk to him about the script instead of just dismissing the slab off. Never assume the patient is going to have problems.

     

    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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