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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.”

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?

 

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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.

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

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Real Deal

How Did This Trunk Show Turn Out So Wrong?

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

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

ABOUT REAL DEAL

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

ABOUT THE AUTHOR

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

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

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

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

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

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

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

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

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

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

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

“Right,” Mike replied feebly.

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

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

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

John and Mike looked at each other weakly.

The Big Questions

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

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

Anissa L.
Berkeley, CA

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

Scott K.
Dover, OH

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

Judy C.
Virginia Beach, VA

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

Lois S.
Winter Park, FL

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

Jenna G.
Fargo, ND

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

Jon L.
Madison, IN

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

Alicia M.
Anchorage, AK

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

What’s the Brain Squad?

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

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Real Deal

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

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

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

ABOUT REAL DEAL

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

ABOUT THE AUTHOR

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

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

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

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

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

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

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

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

“Sure, what’s up?”

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

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

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

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

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

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

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

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

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

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

“That’s a big ‘if,’ Ellen.”

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

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

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The Big Questions

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

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

Cory S.
Las Vegas, NV

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

Caitlin W.
Montrose, CO

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

Missy D.
Spokane Valley, WA

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

Pat R.
Irving, TX

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

Judy M.
Pittsfield, MA

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

Judy C.
Virginia Beach, VA

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

Jennifer L.
Dansville, NY

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

Leisa L.
Newport Beach California

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

Rigo L.
Indio, CA

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

Stewart G.
San Francisco, CA

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

Pablo M.
Alpharetta, GA

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

M. Pastor
Phoenix, AZ

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

Donna
Mission, British Columbia

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

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Real Deal

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

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

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

ABOUT REAL DEAL

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

ABOUT THE AUTHOR

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Big Questions

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

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

Thomas W.
Myrtle Beach, SC

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

Deanna A.
Fort Collins, CO

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

Brian C.
Prescott Valley, AZ

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

Chris D.
Tampa, FL

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

Cherlyn F.
Decatur, IL

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

Pamela M.
Highland, CA

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

Taylor K.
Ellington, CT

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

Judy C.
Wilkes-Barre, PA

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

Pam P.
Downers Grove, IL

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

Martha D.
Wheatfield, IN

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

Dennis I.
Monroe, CT

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

Rigo L.
Indio, CA

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

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

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