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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.

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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

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.

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 Would You Handle This New OD’s Credentialing Crisis?

Her ethics are being tested on her first day on the job.

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LLOYD & ASSOCIATES was a successful private practice in North Dakota employing four optometrists and 20 staff. Earlier in the year, Dr. Lloyd had purchased a small two-lane practice in a rural town 45 minutes from his office; the previous owner was retiring but agreed to remain as an employee for six months. That deadline was quickly approaching, so Dr. Lloyd moved quickly to catch the wave of new optometry school grads.

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

Three applicants visited for interviews, but student-doctor Dunne was the clear choice. After aggressively negotiating against competing offers, she signed a lucrative contract with Dr. Lloyd. Her final month of school was followed by a month backpacking in Europe; during this time the practice processed her state license and began booking her patients.

Dr. Dunne spent her first few days of work completing a mountain of paperwork, watching EHR webinars and observing the techs. That Thursday afternoon she sat down with Dr. Lloyd to discuss tomorrow’s protocol.

“Your first day seeing patients is going to be pretty busy!” said Dr. Lloyd enthusiastically, handing her a printout of the schedule. “This column over here indicates the insurance they have.”

Dr. Dunne scanned the page. “Okay, three Medicare, two cash-pay, a UnitedHealth, three VSP and one EyeMed,” she recited.

“Don’t click ‘sign-off’ on the chart in EHR,” instructed Dr. Lloyd. “The insurance team will do the rest of the work for you since we’re billing your charts under my name.”

“That’s legal?” asked Dr. Dunne.

“It’s what we’ve done for all the other associates,” he said. “Until you get credentialed, we’re forced to bill under my ID. I’ll try to look over some of your charts in the beginning, when I have time.”

“How long does credentialing take?” she asked.

“It can take several months, depending on the panel,” he replied.

Dr. Dunne rubbed her chin worriedly. “This doesn’t feel right. I mean… I could get in trouble!”

“What arrangement were you expecting?”

“Most of my friends are starting off as super-techs: the practice owner comes in at the end to confirm findings. Between patients, they learn about billing or work on projects,” she explained.

“I’d have to pay you a fraction of your base,” said Dr. Lloyd. “And I really don’t need a super-tech. I need a doctor who can work independently, as I said in your interview. I have too many patients of my own to check your work.”

“Can I see cash-pay patients for now, until I start getting approved?” suggested Dr. Dunne.

Dr. Lloyd shook his head. “Your schedule is built for the next three weeks, and I’d say only 5-10 percent are cash-pay. We need you to generate a certain amount each week to justify your pay.”

He started to clear the table, visibly frustrated. “I suggest you speak to the other associates for reassurance. I have a satellite location that will be without a doctor very soon.”

Instead of speaking to the other doctors, Dr. Dunne went home to call her best friend.

“He said the other docs did it, so that sounds reassuring,” her friend offered.

“If they want me to bend the rules on my first day, who’s to say there won’t be more sketchy compromises?” she replied.

The Big Questions

  • Obviously this discussion should have happened earlier; now both parties feel duped. Can you identify a compromise?
  • Is it fair for a practice owner to expect a new doctor to agree with pre-credentialing protocol without discussion/collaboration?
  • How should a new doctor identify and enforce her own ethical boundaries? Should it be a component of an employment contract?
Jonah H.
Sacramento, CA

Compromise is a state of life when dealing with third party payers. They should have told them that in optometry school.

Of course, this should have been part of the initial discussion so that the new associate could consider/investigate their comfort level with the arrangement. It also should have been written into the agreement that a “billing bridge” must be constructed towards full credentialing.

Here’s the compromise:

The new associate should get to work and kill it.

The owner should agree to block off one or two hours at the end of each week to sit with the new associate and review any cases he/she is uncertain about, and sign off on all charts—taking full responsibility for any errors.

Richard S.
Richmond, KY

In the case of a new graduate, the optometry school has missed something that they should counsel and help new graduates with. Since this is part of private practice, they should teach and help understand insurance companies and help them get credentialed.

Secondly, this is an insurance company issue. With so much technology available, why does it take so long to get credentialed? It is absurd!

Since no one seemed to care enough to deal with these issues, if I were the new doctor, I would not even consider balking at whatever was necessary to begin seeing patients immediately.

Although it should have been discussed earlier, because it is common practice at that particular office, I understand why the owner might have not thought about it.

John B.
Copperas Cove, TX

The super tech idea is the best until she is credentialed. Dr. Lloyd should find the time to look over each and every file and, better yet, he should participate in some concrete, hands-on way to justify the use of his ID for the insurance claims.

David E.
Little Rock, AR

I don’t know what is acceptable here, but am very interested in what other docs have to say. How likely is it that this arrangement would cause problems for either or both doctors? Is this a commonplace arrangement?

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

When This Doc Moved to a Concealed Carry State, She Didn’t Expect Staff to Be Packing

What would you say to an OD who balked at legal firearms in her office?

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DR. COLTAN, A recent NECO grad, was taking a risk. She and her husband, both avid hikers and snowboarders, had relocated from Rhode Island to Colorado to open a new solo practice. Over the last several months, between per diem shifts at local practices, she had worked to build her new office.

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

Soon the time came to begin hiring employees, a task Dr. Coltan had been dreading. She had never even interviewed someone before, but within a few weeks she was able to secure employment contracts with Barbara, a receptionist/insurance biller, and Doug, an optometric assistant who had some optical knowledge.

Barbara and Doug helped Dr. Coltan a great deal with promoting the office leading up to the grand opening, as they had connections with many local businesses and community leaders.
On Dr. Coltan’s first day in business she was ecstatic about the seven exams her team had scheduled. The day flew by for everyone, and after locking the doors she invited Barbara and Doug to the break room for pizza and cake.

“Thank you so much for all your hard work today, and for pounding the pavement this last week!” she said, her eyes misting up.

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“You’re very welcome!” said Doug. Barbara, seeing Dr. Coltan’s emotional expression, reached out and gave her a big hug.

“Thanks Barbara,” she said, sniffling. As she dropped her arms she whacked her hand against something hard on Barbara’s hip. “Oh! Ouch,” she exclaimed. “Oops, are you okay?” asked Barbara.

“What was that?” Dr. Coltan wondered aloud.

Barbara swept her long cardigan back to show Dr. Coltan her sidearm. “I have a concealed carry license,” she said casually.

“Whoa!” Dr. Coltan’s heart skipped a few beats. She had never seen a handgun up close before, and instinctively backed out into the hallway. Doug and Barbara chuckled at her reaction, but Dr. Coltan felt her stomach turn in knots.

“It’s okay!” Barbara called out, “I’ve worn it for fifteen years. It’s an essential safety measure for the office.”

Dr. Coltan, still looking in from the hall, shook her head slowly. “It doesn’t make me feel safe,” she said quietly.

Doug and Barbara gave her a look of surprise. “There will be a lot of patients carrying,” Doug said. “This is Colorado. That’s just the way it is here.”

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The next day, Dr. Coltan found herself avoiding Barbara. She used the phone pager system rather than talking face-to-face and kept clear of the break room during the receptionist’s lunch break.

That evening, she brought up the issue with her husband.

“I don’t know if I can live like this,” Dr. Coltan sighed. “I feel hyper-focused on the hip or pocket of every person that walks in, wondering if they have a gun!”

“Can you put a sign in the window telling people they need to leave their guns in the car?” he asked.

“I mentioned this to Doug today, but he felt sure I’d lose patients,” she said. “I can’t believe I am on edge in my own office… I feel so blindsided by this.”

The Big Questions

  • Should this new business exclude a portion of the local population? How would you phrase signage at the front door?
  • Barbara is an asset to the practice, has done nothing illegal, and is not willing to stop carrying. How should Dr. Coltan proceed?
  • If you work in a state that allows it, how do you feel when interacting with patients who are carrying?
Darrell L.
Goodlettsville, TN

Interesting and thought-provoking Real Deal. The gun debate. A politically charged topic meets office management. I am a Tennessean, from the Nashville area, an optician/owner of a mom and pop optical shop and a believer in self-preservation. Through 40-plus years of dispensing, I have worked with numerous trainers and law enforcement, teaching them how to cope with presbyopia and the front sight. Yet, it is not just those who are paid to protect us, the general public has been coming to me for years who carry, some concealed and some open. At the age of 12, I was given the 12-gauge shotgun you would probably expect a Southern boy to get. I was also taught the proper use of the gun. If you don’t know how to use a tool, whether a lensometer, a hammer or a gun, then don’t pick it up. The doctor did a great job hiring. Barbara and Doug are working for the doctors’ best interest. “Avid hikers and snowboarders” and moving to Colorado implies they did visit before they moved. In Colorado it is legal to carry both concealed and open. Somewhere along the way they should have encountered locals who openly carried. Therefore she should not have been “blindsided” unless she had put on blinders. The first thing the doctor and her husband should do is take a handgun safety course to alleviate the fears they have. I’m not advocating that they buy a gun; they will be better educated after the course to make that decision themselves. They took a risk and moved to Colorado; I’d be more afraid of the bears. Partly, I feel sad that we live in a time that more of the populace feels the need to carry protection. Partly, knowing the person carries and has passed the course to own and carry making them one of the good guys, I feel relaxed. The gun is not the issue—that person needing my service is. But in the end, the doctor has every right to seek like-minded employees, have a pleasant office atmosphere and to decide who meets her criteria for patient base.

Joyce P.
Raleigh, NC

Usually those who have licenses to carry are doing it for protection, not to run out and start shooting the world up. We need to be more concerned about those who are carrying illegally, not legally.

Daniel M.
New York, NY

If you move to a state with open carry laws you have to accept that people will do just that.

Douglas C.
Beachwood, Ohio

Fear is derived, in this case, from ignorance. Dr. Colton needs to go to a range and take a class on gun safety and learn how to shoot. Doing so will allow her to gain an understanding of firearms and will make her more comfortable around them. When people conceal carry, you don’t know they have a gun … but are you safer around them or around someone who you know has one? There’s no difference. The doctor should have a gun policy for the office that states that people who are legally allowed to possess a firearm should be allowed to have it. Whether she likes it or not, it’s legal.

Brian C.
Prescott Valley, AZ

My office is in the Wild West of rural Arizona. Lots of people open and conceal carry weapons. I am not anti-gun. I grew up with weapons, so I was trained to properly care for and shoot pistols, rifles and shotguns. Took hunter’s safety classes as a teenager. I hunted elk, deer, duck, geese, doves for years. I own a shotgun currently. It is locked, unloaded, action open with a gun lock in the action, and the ammo is safely stored in a separate location. I put up a sign on my door that reads “No Firearms Allowed by Section 4-229” that AZ approved several years ago. I see them at the local VA I work in, at the local hospitals, and all the private practice MDs in my area. I am not an outlier on this issue. I did this because in the news at the time, somebody carried a concealed firearm into a business and dropped it causing a discharge (nobody got hurt). At the same time, I had a patient come in wearing TWO .45 ACP semiautomatic Colt pistols in holsters, open carry (Wyatt Earp style). He was wearing camouflage pants and black shirt with menacing writing on it. He revealed in his medical history that he had mental illness. This made my staff very nervous. In the lobby, I nicely asked him to leave his pistols in his car for the exam, showing him the 8×11 color sign on the door. I stated that in the 20 years my office was open that we never had a robbery or shooting or a need for a pistol. He huffed that I was “infringing on his second amendment rights.” I told him he could either leave the guns in the car for the exam or see another gun-friendly OD or MD down the street. He canceled, walked out the door and I haven’t seen him since. I frankly don’t care if I lose the business of people who feel (logically or illogically) that they need to carry a gun everywhere because they perceive a threat (real or unreal). My point is:

1. My office is my private property. I will do what makes me comfortable and safe. I will do what keeps my staff and patients comfortable and safe. I will control my office and what happens in it.
2. My office will be sued if a gun-toting person shoots or discharges a weapon that hurts anybody else. I need to limit my liability.
3. If you don’t feel your life is in immediate danger, then you don’t need a gun. If you feel your life is in immediate danger, and that you really need a gun, then you probably don’t need an eye examination right now.
4. Car accidents killed 11.9 people per 100,000 people in 2017. Guns killed 12.2 people per 100,000 people in 2017. I don’t let people drive cars in my office. I don’t let people have guns in my office either. Accidents killed 00.0 people per 100,000 in my office from 2002 to the present, and I intend to keep it that way.
5. This is not a political issue. It’s a common sense issue.

Sherri H.
Kansas City, MO

In states where conceal and carry are commonplace, to ask someone to leave their firearm in the car could indeed cause them to go someplace else. Dr. Colton feels very uncomfortable because she has not been around firearms. Maybe she should take a conceal carry class to get familiar with what conceal carry is all about. She might even feel empowered by the knowledge and know-how of handling a firearm. I personally feel more comfortable when I know someone is around with a conceal carry on them. She should also talk with other doctors in her area for their advice on this topic.

Angel M.
Cynthiana, KY

Pro- or anti-gun, that is an overly phobic reaction by Dr. Coltan to a trusted staff member. Maybe Coltan should seek counseling or move, because she can’t plant herself in a state that has a conceal carry culture, and demand that the patients and staff change for her. PS: Y’know, she has a gun right in her name…

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Tory M.
Dumas, TX

I would tell Dr. Coltan her fear is unreasonable and is because of unfamiliarity with firearms. Bad people conceal weapons all the time and you weren’t scared about that possibility? If not, you’re very naive. It was only after you were aware of it that it caused irrational fear. People are surprised if I mention I’m carrying concealed, because they can’t tell. Not the fact that I carry, but that they couldn’t tell. My advice is to ask the staff member to take you to the range and learn how to handle one safely and see what it’s like. It’s fun. And it’s freeing if you have a fear of firearms. Just like learning to drive a car, using a power tool, checking angles before dilating to prevent angle closure glaucoma, etc. If you are familiar, nothing to fear. You are going to have people ask you about prescriptions for using firearms; whether long rifles, shotguns or handguns. You might as well have a little knowledge about how they work to be a better expert too.

Brandy W.
Atlanta, GA

1.) You should absolutely NOT exclude concealed-carry patients from your practice.
2.) Dr. Coltan should expand her horizons, take a weapons safety course and learn. She clearly has zero experience whatsoever with weapons, and it seems she is making a judgment based on fear instead of education. I believe that she should respect her employees’ right to defend themselves, which is something she cannot do.
3.) I love to see patients carrying, or anyone for that matter — it makes me feel safer. I also conceal carry and rarely go anywhere without the means to defend myself. Many criminals carry weapons — we know this. I want to be able to level the playing field.

Julie U.
Jupiter, FL

I think the doctor should accept her employee with her weapon … she did before she found out. It is really great for the staff. Heaven forbid if someone came in with a weapon. At least they are protected. I carry in my business too and when customers find out we tend to talk about it in a positive way. The world is a different place, sadly, then it was years ago. I say CARRY on.

Dr. Craig F.
Rushville, IN

I have no problem with someone legally carrying a concealed weapon. This doctor should roll with the punches and learn to live with it. When she goes to the grocery store, or shopping at retail locations, she will be walking by other people that are carrying concealed weapons. Maybe she should take a gun safety class so she can understand the benefits and risks of carrying vs. not carrying a weapon.

Dennis M.
Cedar Park, TX

I’ve been a concealed carrier for over a decade and I suggest getting more educated on self-defense. Those of us with LTC are good people that have had EXTENSIVE background checks. Yes, it’s a way of life for a big portion of our country and is growing larger every day. I would suggest taking self-defense/beginner shooting classes and get to know the community. I’ve taken many first-time shooters to the range and seen their faces brighten dramatically. You don’t have to own a firearm, just be familiar with them. They’re not bad at all if you respect them and be responsible.

John L.
Nashville, IN

Ultimately, the decision of whether a staff member carries a firearm while at work lies solely with the practice owner. There may be serious legal or insurance issues that the doctor may want to discuss with her lawyer. Hoplophobia is a real problem with some people and the decision to relocate to a less conservative area may be necessary. Shooters, particularly presbyopic ones, have special visual needs, something that may help build a new practice.

Dennis I.
Monroe, CT

Dr. Coltan needs to grow up and be more tolerant. In fact, I think she needs to spend a little time at the gun range getting trained in the use of firearms. Who knows; maybe she’ll like it? Fear of guns is irrational. More people die at the hands of a drunk driver than the wrong end of a gun. She is not afraid of cars or beer, is she? Yes, this hit a nerve with me; as I have lost very young patients to gun violence (Sandy Hook). Guns don’t kill people. People kill people. Learn to handle the (whatever object causing fear) and fear goes away.

D Bailey
Huntsville, AL

We all have certain rights that we can choose to exert or not. I have a license to drive a car, but my boss won’t let me park in the spaces saved for our patients. I can buy alcohol, but the doc won’t let me drink at work. We have policies covering these issues. If I don’t agree with the polices, I can always find another job. The owners should set their policies to reflect the type of business/environment that makes them comfortable. As an employee or as a patient, all that is important is that the doctor is providing exemplary service. If so, they will have many people wanting to work and see them, regardless of whether they allow dogs, alcohol, legal marijuana, and yes, even guns on their property.

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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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Published

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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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