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Real Deal

A Pregnant Biller is Anxious About the Billing Decisions of the OD. Here’s What You Would Do

It’s the case of the uneasy momnesiac.

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COEUR D’ALENE, Idaho’s newest optometry office, was quiet on a late spring afternoon. Optician Ryan was sitting at the reception desk reviewing patient satisfaction surveys when the phone rang.

ABOUT REAL DEAL
  • Real Deal scenarios are inspired by true stories, but are changed to sharpen the dilemmas involved. The names of the characters and stores have been changed and should not be confused with real people or places.
  • ABOUT THE AUTHOR
  • NATALIE TAYLOR is owner of Artisan Eyewear in Meredith, NH. She offers regional private practice consulting and ABO/COPE approved presentations. Email her at info@meredithoptical.com
  • “Good morning, Dr. Ballard’s office, how can I help you?” said receptionist Blake, seated next to Ryan.

    “This is Richard Hunt,” an elderly voice bellowed. “I am at the pharmacy and the girl is telling me you never sent my prescription!”

    Blake smacked her forehead. “I’m so sorry Mr. Hunt, it’s my fault, just sit tight and I’ll fax it over right now, it won’t be five minutes,” she said. As she reached for a stack of charts she caught Ryan’s eye and grimaced apologetically. “Mommy-brain!” she declared.

    Ryan smiled agreeably, and turned back to collecting complaint cards for call-backs. A few moments after Blake sent the fax another call came in.

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    “This is the pharmacist, you faxed over a prescription dated in 2014 for the wrong patient. I need the current script for Mr. Hunt’s eye drops.”

    “I’m so sorry,” said Blake. “I’m seven months’ pregnant and it’s making me a bit foggy. I’m sending it now.”

    Ryan got up to help send Blake’s fax. She was flushed and distracted.

    “Everything okay, Blake?” he asked.

    “Well, I keep putting people on hold and then forgetting about them,” she confessed. “I scheduled a lady at 7pm tonight but I guess I said 7am and of course when she came the doors were locked. She left the practice because of me. Just today I messed up that guy’s eye drop prescription – twice!”

    “Do you really think you’re foggy because of the pregnancy?” he asked.

    “I’m afraid to even acknowledge it!” she said, tearing up. “I’m worried by what might happen next.” She shook her head hard and spoke softly. “It’s not just that. I’m so uncomfortable with the billing decisions Dr. Ballard is making.”

    “What are you talking about?” he asked.

    Blake fidgeted in her chair. “If we ever got in trouble, my name is recorded as the biller. I’m liable.”

    “I noticed you’ve had a few long meetings with him recently,” said Ryan. “What exactly is he asking you to do?”

    “Well, for lots of patients he’s having me bill both the health insurance and the vision plan for a comprehensive exam, instead of choosing one,” she explained.

    “There are also a lot of level five codes, and they don’t have adequate documentation to be more than a level three.”

    “If it’s his business and that’s what he wants to do, wouldn’t the insurance companies know that you didn’t really have a choice?”

    “I genuinely don’t know! But I hate being in this position. It isn’t like I can walk away from health insurance right now.”

     

    The Big Questions

    • What would you do to mitigate the growing number of mistakes Blake is making?
    • How should Blake reach a compromise with Dr. Ballard regarding billing ethics?
    • Is there a good solution for billers when they disagree with the practice owner’s directives?
     

    Expanded Real Deal Responses

    Judy C. Wilkes-Barre, PA

    “Pregnancy brain” is real, although temporary. It’s a combination of hormones and poor sleep. It will pass. The doctor may not realize the situation created when billing inappropriately. Document the billing concerns and research the possible penalties. Meet with the doctor to discuss his vulnerabilities. For the biller, document, document, document.

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    Robert M. Edina, MN

    Besides being pregnant, Blake is stressed out by being asked to do something marginal at best. For the billing, first establish written protocols on billing vision plans and medical and what is needed to bill the higher levels. Then she should meet with the doctor and lay it out. He should be aware that if the level is not supported by documentation there will be consequences if audited. He may not be aware of the rules and protocols.

    Chani M. Highland Park, NJ

    There are two issues here; Blake’s mistakes, as well as her discomfort with the billing. It’s unprofessional of her to blame her mistakes on her pregnancy. Millions of pregnant women work and don’t screw up. If she is screwing up because she is stressed from fraudulent billing that’s a different problem. She needs to firmly tell the doctor that this is not legal and she is not comfortable doing it. Ideally, she should resign, but with a baby on the way the economics probably don’t support that. If Dr. Ballard is fraudulent with the billing, what other questionable things is he doing?

    Texas S. Citrus Heights, CA

    1. Have a stack of Starbucks cards ready for any goof ups. I find my patients very understanding when things go wrong, and they will. 2. Bill however the doctor dictates, but be sure to have the doctor review and sign all billings. This should be in an office manual. 3. Have a discussion with the doctor about the concern should they be audited … and they will be audited. The doctor is also at the mercy of an unhappy employee who knows about the billing and decides to become a whistleblower. It’s always best to stay within the rules.

    James W. San Diego, CA

    1. Document the mistakes and create a paper trail. 2. Blake is making numerous mistakes. How do we know the billing issues are not Blake’s issues? Perhaps some items are to be billed medically and others optically. 3. Speak to the doctor and be direct. If the doctor is doing something incorrect then immediately create change. Clean up your act or the associate will most probably communicate the ethical issues to the insurance company.

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    Linda H.Littleton, CO 

    You can bill both medical and vision; but level 5 with an OD is red flag. Most MD’s are hesitant to submit a level 5 even with proper documentation. Most will downcode to level 4 just to keep off the radar for a potential audit.

    Dr. Scott K. Dover, OH 

    In my experience, when a staff member is making more mistakes than normal, there is usually an underlying issue. (stress at home, stress at work or being giving more extra tasks than that person can handle). In this case, the combined stressed of being pregnant and worried about the ethics of the billing problem are causing the forgetful issue. I would even say the billing problem is the bigger stress issue. She should first discuss the billing problem with the office manager and let that person help solve the problem. If there is no manager or she doesn’t feel it was handled properly, she must confront the doctor and state her feelings. She needs to document everything before and after the meeting. If they disagree, the compromise would be to ask an outside billing source or consulting group for help. One should never risk anything illegal – no job is worth that risk.

     

    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

    A Sublease Eye Doc Didn’t Work Out

    Should the optician/owner pursue their non-compete?

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    ROXANNE WAS AT HER desk on a Sunday afternoon reviewing bills and rubbing at stress hives on her neck. The optician-owner of a gorgeous boutique near Sioux Falls, Roxanne was at her wits’ end with her sub-leaser, Dr. King. The women had a meeting scheduled to try to resolve their differences.

    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

    The pair met the previous year at a CE event and hit it off. Dr. King, a stay-at-home parent of several years, was inspired to return to work part time, and Roxanne was inspired to offer eye exams to her loyal client base. They created a two-year contract including a non-compete clause limiting Dr. King from practicing within 3 miles of her office within a year of contract termination, on penalty of several thousand dollars. Once the commitment was made, Roxanne retrofitted storage space into an exam lane and purchased second-hand equipment.

    Roxanne, waiting impatiently, now ran through the details in her mind to prepare for a contentious discussion. The terms of their agreement were 8-10 comprehensive exams in 4 hours for a flat rent. Patients scheduled with Dr. King directly so she could book around her family commitments. She billed and collected all exam fees, while Roxanne’s employees pretested, collected co-pays, and processed contact lens orders.

    For a few months everything went well. Then the financial disagreements began: Dr. King started scheduling just 2-3 patients a day and decided it would be fair to only pay rent every second or third week. Payments on the equipment leases were now greater than the rent. Roxanne was also seeing lots of shipping charges for contact lens trial orders, which Dr. King felt were the responsibility of the business as they profited from supply sales.

    The front door squeaked and a moment later Dr. King sat down at Roxanne’s desk. She looked worn but resolute. “I know you called this meeting,” she began, “but I’d like to speak first.”

    Roxanne nodded and pushed her paperwork to the side. “Okay, I’m ready.”

    “I’ve given it a lot of thought, and I just don’t think this is a good fit for me,” said Dr. King. “I’m tendering my resignation, effective 2 weeks out. I don’t have any patients booked past then anyway.”

    Roxanne’s eyes bugged. “You’re quitting?!” she managed to get out, throwing her head back and staring at the ceiling. “You’re quitting.”

    “This just isn’t fun for me,” she continued. “I don’t like your stress towards me, and I feel like I’m being nickel-and-dimed.”

    “Are you leaving to go work somewhere else?” asked Roxanne.

    “No, my wife and I don’t rely on my income,” she said.

    Roxanne sighed. “Well, it sounds like your mind is made up. It stinks we weren’t able to resolve things, but … I get it.” As soon as Dr. King left, Roxanne got to work posting the job vacancy online.

    A few weeks after Dr. King’s last day, Roxanne’s lab tech stopped her in the hallway. “I just heard through the grapevine, Dr. King is seeing patients over at Family Vision Center,” he whispered. Exasperated, Roxanne thanked him and went to call her lawyer about enforcing the non-compete clause. Family Vision Center was less than 2 miles away!

    The Big Questions

    • In what way could Roxanne and Dr. King have changed their agreement to mutually improve the situation?
    • If Dr. King bills for a contact lens fitting and the boutique bills for the supply, who pays the shipping and handling of trial lenses?
    • Is a non-compete clause justified for a sublease doctor? If the lawyer deems the contract enforceable, would you pursue?

    Expanded Real Deal Responses

    Andy H.
    Jacksboro, TN

    This scenario poses a significant problem for the optician/owner. I’m not sure how I’d resolve this situation, but it could’ve been avoided if a reputable business consultant had designed the contract. A professional consultant would have covered all the disputed variables. I think it’s interesting that a recent INVISION survey showed a mere one in four ECPs use consultants, and this Real Deal demonstrates the need to do just that. We’re all pretty smart about eyes, but not many of us can claim to be experts in business.

    Chris G.
    Inver Grove Heights, MN

    First, I didn’t see a copy of the non-compete document. Some of these documents are unenforceable depending on the laws in the state where this occurred. Second, all costs should be negotiated at the beginning of the employment. Third, even if a lawyer deems the contract enforceable, it can still be nullified by a myriad of other factors. Having said this, if all the contingencies are met in the agreement and it is enforceable, I would go after it immediately. Another part is who owns the files in the office. That should be negotiated as well.

    Bill K.
    Houston, Tx

    Bad terms of agreement upfront. Starts bad, ends bad.
    1. More concrete terms and understanding.
    2. Cost of trials? Ever hear of fitting sets?
    3. Non-compete should hold up if written correctly.
    Not a bunch of 2-year-olds at play. Grow up and live up to your commitments. “I don’t feel like I am respected.” Blah blah blah.

    Anna T.
    Claremont, CA

    First of all, they should have spoken more about what was expected from the lease. Possibly going through a broker to have a legal agreement prepared with terms stating that the lease was to be paid every week and that X amount of patients were expected per week. Also, they should have agreed upon the costs of the lenses, and who was paying for shipping charges in the agreement. Ultimately, I think that the doctor just did not have the right work ethic for this sort of collaboration. I think that the doctor’s fees should cover the trial shipping costs. I believe the non-compete is justified. However, since this doctor did not spend very much time working at the location, I am not sure that she would be much competition if she were to set up office in a nearby location. Most likely with her work ethic she would not be much of a business owner in the future.

    Rigo L.
    Indio, CA

    Ohh, the drama! It’s always easier to blame the other person. Both Roxanne and Dr. King gave up too soon; communication is key. It was unprofessional for Dr. King to quit. It’s not expected but the doctor should feel heavily responsible — in this case it looks like it was all business. The shipping and other stuff could have been worked out if both were willing to keep to their agreement; at the end of the day they still made a profit. As far as pursuing the non-compete clause, it sounds exhausting, expensive and time-consuming, but if this is going to save my business, I would go ahead with it.

    Darrell L.
    Goodlettsville, TN

    The contract should have spelled out the particulars of fees, bills and supplies. Leaving things open-ended always creates problems. The non-compete is justified and was agreed to in writing, therefore it is binding. If the tables were turned, the doctor would likely pursue reimbursement for damages from the optician.

    Frank U.
    Bakersfield, CA

    No lawyer; lesson learned, find another doctor.

    Wilfredo M.
    Philadelphia, PA

    Unless Roxanne and the doctor agreed to bringing another doctor to work more hours, I don’t see how. Two or three exams a day doesn’t justify the expense of equipment, or cutting the space to put in an exam room.

    The optical should pay for shipping for trials, but also keep in mind that for trials at least a commitment for the sale of the contacts should be engaged, or an order for glasses should be placed — and then seen as a courtesy from the optical, not from the doctor.

    Whatever is the right and legal thing to do. If the income was not the issue based on Dr. King’s answer, why work in a place that close? People should not be allowed to conduct a market study while working with you and then become your competition! Keep in mind that patients are the “property” of the doctor, who did the billing.

    What’s the Brain Squad?

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

    Continue Reading

    Real Deal

    A Compensated Lens Design Tripped Up This Eye Doc

    The patient wants his glasses and exam refunded.

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    IT WAS A BRIGHT SATURDAY morning in Baltimore and Dr. Garcia’s optician Elena was engrossed in auditing last month’s lab bills. Ten months ago she had been recruited from a bank teller position by Dr. Garcia. His previous optician had quit unexpectedly, and after a month of trying to hire someone with experience, the optometrist trained Elena himself.

    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. Garcia interrupted her concentration with a patient hand-off. “Elena, you may remember Victor, he had an exam a month ago,” he said. Victor and Elena nodded to each other in recognition. “Well, Victor had his glasses made down near D.C. and they aren’t right.”

    Victor handed Elena his spectacles: progressives in a drill mount frame. “I just picked them up yesterday. Since I live closer to you guys, and you did the exam, I thought I should have you check them.” He threw his hands up in exasperation and added,

    “I just can’t drive in them!”

    Elena cradled the frame. “Let me read the lenses, I’ll be right back!” Victor sat down at the dispensing table and Dr. Garcia followed the optician into the lab.

    “I checked them already,” said Dr. Garcia quietly. “They’re off — the left lens in particular is 12 degrees off-axis, and the right lens has cylinder even though I didn’t prescribe any. Look at the add power — I wrote for 2.50, but they made a 2.44 and a 2.45. What the heck is that?!”

    Elena gave Dr. Garcia a look of shock. “What should we do?” she asked.

    Dr. Garcia squinted through a few thoughts before grabbing the frame from the lensometer.

    “Follow me,” he instructed, heading back to his patient.

    “Victor, these lenses aren’t what I prescribed,” confirmed Dr. Garcia. “You can go back and tell them to make them again, but if I were you I’d ask for a refund and get your glasses made here.”

    Victor frowned. “Fine, I’ll get a refund the next time I’m in D.C. I just want glasses I can use,” he said.

    Elena helped him find a flattering acetate frame, took his measurements and promised a quick turnaround. Dr. Garcia took the job directly to the local lab before work on Monday, and on Wednesday afternoon the patient, delighted, picked them up.

    The following Wednesday evening, Victor was back again. Dr. Garcia was with patients, but he found Elena in the lab.

    “I took these glasses back to the place I got them from, told them you said they were made wrong and asked for a refund,” he recounted. “The owner drew on them with a marker and spent about 15 minutes bending them, and then I saw great. He said if you guys think they were made wrong, you shouldn’t be in the eyeglasses business!” Elena’s face flushed and her eyes started to burn. “I obviously want to return the pair you made me, as I don’t need or want two pairs of glasses. Frankly, I see better with the other pair anyway.”

    “I’m so sorry about that,” stammered Elena. “Dr. Garcia approves our refunds and the bookkeeper issues the money.”

    “Fine, here are the glasses,” he said, handing her a beat-up gift bag. “I expect that recheck visit to be refunded too. Completely ridiculous,” he muttered, and stormed out.

    The Big Questions

    • Dr. Garcia is clearly unfamiliar with compensated lens designs. Is there anything anyone could have done better in this situation?
    • Elena now has a returned frame that has been worn a week. Should it go back on the board for resale?
    • Victor is insisting his recheck fee of $50 be refunded. How should Dr. Garcia proceed?

    Expanded Real Deal Responses

    Rachael D.
    Burlingame, CA

    I find these situations very tricky. You don’t want to call out the doctor or make any accusations and potentially ruin a business relationship. Assigning blame doesn’t necessarily instill confidence in a patient or client either. I would have printed out the compensated lens Rx and discussed that with the doctor and patient. The numbers game can be very deceiving. I would have encouraged the doctor to contact us to discuss her findings before making statements that may not be true. I would afford her the very same professional courtesy. There shouldn’t be a fee for a recheck if she did the original exam. The frame gets donated.

    Manuel L.
    Midland, TX

    Dr. Garcia should have checked the glasses on the patient’s face, made proper adjustments, tried to bend the axis maybe 2 or 3 degrees, and probably could have made the Rx work. He never should have charged $50 for a recheck. That should have been considered a bit of professional service gratitude.

    Taylor K.
    Ellington, CT

    1. Dr. Garcia should have had Elena contact the fabricating location and learn more about the lenses. Elena could recommend to the dispensing location the doctor’s suggestions to address the patient’s issues before encouraging the patient to order a new pair. We would never force a new pair on a patient unless it was their idea, and we would emphasize that we do not return orders.

    2. Elena will need to assess the wear on the frame. If it is in great condition. then clean it, add new demo lenses, and put it back on the board. Otherwise, return it under warranty.

    3. I would advise the patient that because there was not an issue with the prescription, they are responsible for the re-check fee. I let the patient know for future reference that had our office made the glasses or there was an error in the prescription, then there would be no charge. The dispensing office’s errors do not constitute free chair time for a patient that is not loyal to the practice.

    Yen N.Dallas, TX

    Digital or high index lenses have been known to cause a compensated Rx. Not knowing the difference, since he may not be knowledgeable about that, the doctor probably assumed they were made incorrectly. (I know this from personal experience.)

    Knowing all lens possibilities in this industry — whether doctor or optician — is vital so that there are more reasonable conclusions for the guest. Ask more questions about what the client purchased, and what type of specific vision issues could be ruled out by adjustments. The frame could be marked down, with the next customer being informed that they were a frame worn and returned within a week. But get it cleaned and polished by the lab before putting it back on the shelf. If your business does not do that then request an RA if possible. The recheck fee should definitely be returned. The client should not have to pay for something that did not benefit him. A lost customer is not worth the $50 in the end.

    Leisa L.
    Newport Beach, CA

    Before Dr. Garcia and his optician suggested returning the drill mount glasses, there should have been more communication with the patient regarding the actual areas where his vision was not comfortable. Adjustments could have been made by Dr. Garcia’s office staff to correct the problems. The patient was charged a recheck fee, which is questionable considering the original Rx was done by Dr. Garcia. The end result would have been a better relationship between Dr. Garcia’s office and the patient.

    Yvette R.
    Cincinnati, OH

    Adjustment should be an additional consideration when a patient says that he cannot see. Dr. Garcia would benefit from a continuing education class on digital lenses and position of wear. He needs to arrange for Elena to receive training from a lab rep. Elena could ask Dr. Garcia if the extra pair of glasses could be given to the angry patient as a back-up pair and a gesture of apology. I would refund his re-check fee as well, and hope that he returns for his routine exams.

    Bob S.
    Pinellas Park, FL

    Both the doctor and Elena need to get up to date on lens technology. They need to request help from a lens rep and take some CE courses on the subject. If the frame is not damaged it could be sanitized and go back on the board. His recheck fee should be refunded since it was unnecessary.

    Charley A.
    Hurst, TX

    Cut your losses. Refund all fees subsequent to the initial exam. No one said the “glasses were made wrong,” just that they did not appear to be made to prescription. Confirming the patient’s understanding regarding the follow-up exam and the refund/remake policy regarding the second pair or glasses might have helped. The patient will not remain happy. Be on alert for his return.

    Rigo L.
    Indio, CA

    Let me start by saying this is a rookie mistake by Dr. Garcia. Doctors should never talk money with patients and more so, never recommend patients to return/refund glasses and get them at their office. Elena didn’t do anything wrong; she is not an optician, she is learning the business. We all hate when patients get glasses elsewhere and want us to figure out what is wrong, but the best way to handle this is by sending them back and having the office who made them figure out what is wrong. There was no reason for Dr. Garcia to do an Rx recheck. Even if the glasses were made wrong, they should have been remade correctly before any recheck. Nobody likes the idea of wearing a used frame, but in small optical shops and in cases like these, they are not going to take a loss on a frame. Compensated Rxs are not something new; by now everyone should be familiarized with digital lenses. This looks like a lose-lose situation: lose money and a patient.

    Maureen G.
    Oak Park, IL

    Dr. Garcia clearly needs some CE classes. At the very least get your lab reps in to talk about the latest digital designs and compensated Rx. He should also have Elena go to classes; joining a group such as PECCA would help immensely. If the frame is in usable condition, you can discount it and be upfront about prior wear and definitely refund his money.

    Andrews, MD
    Hurst, TX

    Cut your losses. Refund all fees subsequent to the initial exam. No one said the “glasses were made wrong,” just that they did not appear to be made to prescription. Confirming the patient’s understanding regarding the follow-up exam and the refund/remake policy regarding the second pair or glasses might have helped. The patient will not remain happy. Be on alert for his return.

    Stewart G.
    San Francisco, CA

    1 The only thing I can think of is perhaps calling the place where the patient originally bought the glasses and discuss the issues.

    2. I’m uncomfortable with that, but offices will do that.

    3. It depends on whether or not the Rx was changed radically in the first place. I wouldn’t have charged him in the first place if the prescription had not changed significantly. I would only have done the recheck if the Rx had changed.

    We have a case here of the blind leading the blind. This professional doesn’t know about these lenses and he’s teaching a novice about things he doesn’t even know? OMG!

    Judy C.
    Virginia Beach, VA

    I learned years ago that you can’t make yourself look better by trying to make someone else look bad. The first move should have been for Elena to call the office where the glasses were made and ask for all the pertinent information, letting them know that their mutual patient was unhappy. Simply relying on a neutralization is not enough. Checking the adjustment of the frame should have been the second move. Finally, there is no excuse for not knowing about current lens technology. Education is available from multiple sources and in multiple modalities.

    Rick R.
    Girard, PA

    1. For one thing Dr. Garcia should have never told Victor to return the glasses for a refund and purchase them at his office. I wouldn’t be happy with either office. If the office where he purchased the glasses had to spend 15 minutes “bending them” I certainly wouldn’t be feeling too comfortable. Especially drill mounts.

    2. If the frame was still in good condition, I’d put it back on the board at a reduced price.

    3. Dr. Garcia should give back the recheck fee. Clearly (no pun intended) he was in the wrong.

    What’s the Brain Squad?

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

    Continue Reading

    Real Deal

    An Order is Canceled After the Insurance Company Steals the Work. How Must the Office React?

    An order is canceled after the insurance company steals the work. How must the office react?

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    SECOND LOOK OPTICS, a well-established optometry practice near Iowa City, IA, offers a lot to patients. The optical displays over a thousand frames, the doctors accept all regional insurance plans, and their schedule includes evening and weekend appointments. Late one Saturday, optical manager Zack was paired with new patient, Bonnie, who was on a mission to find the perfect frame.

    ABOUT REAL DEAL

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

    ABOUT THE AUTHOR

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

    “I really like the Warby Parker look,” Bonnie explained. “Roundish, nerdy, and preferably clear with a hint of gold or silver. Do you have that?”

    Zack knew there was an older Kala frame somewhere in a yellowish crystal, and after searching a few drawers in the dispensary he found it. Bonnie put them on and faced Zack.

    “So, I don’t think this is a flattering color on you,” he said. “Also, the keyhole style doesn’t really fit your bridge.”

    Bonnie looked in the mirror and grimaced.

    “Can I pull a few frames together for you to try?” he asked.

    “Yes! I almost bought something like that online … I’m so glad I didn’t,” she said.

    Zack quickly assembled a set of four disparate frames and after half an hour of deliberation Bonnie selected one quite different from her original intention. She and Zack then carefully went through the math to determine if her vision benefit should be applied first to her contact lenses or the eyewear. Bonnie hadn’t had new glasses in six years and was struggling to accept the frame and lens prices, even with the discounts. Eventually everything was settled; Zack entered the orders and collected her co-pays.

    The following Monday afternoon Bonnie called to speak with Zack about canceling her order.

    “I sent you an email; did you read it?” she began.

    Zack found the message, time-stamped 20 minutes earlier. It was a forwarded e-mail from her vision benefit plan, encouraging her to purchase her glasses through their internet portal. It was sent late Saturday evening.

    “I’ve been on the phone with them, and their prices are much more reasonable than yours,” she continued. “I don’t really understand why you didn’t mention this was an option available to me? I made it clear I really need the most affordable pair possible.”

    Zack was unsure of what to say, but Bonnie seemed to genuinely expect him to explain himself.

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    “Well, of course you are not obligated to fill your eyeglasses prescription from the same office as your exam services,” he finally replied. “However, I have already submitted your order to the lab and the work has begun.” Zack held back a key detail: the practice had a strict no-returns policy.

    “I called my insurance and they just told me to call and cancel the order, that they would approve it,” Bonnie replied. “I have the lady’s name I talked to, if you need it.”

    “Okay, I’ll call and then ask our bookkeeper to mail you a refund in the form of a check,” said Zack.

    “Hang on, I also got an email yesterday from a contact lens website. They said I was eligible to try their new brand of contact lenses — which they sell for less than what I paid at your office — and if I did I’d get a $50 gift card to Amazon. So I need a refund on the contact lens order as well.”

    “Your contact lens brand is chosen by the doctor, you’d need to come in for a follow-up exam if you want to change brands,” explained Zack.

    “I don’t think so,” Bonnie said skeptically. “They already processed my order. I even have a tracking number.”

    Zack assured Bonnie the bookkeeper would be in touch and hurried her off the phone to find the bookkeeper.

    The Big Questions

    • Second Look Optics has a no-refunds policy. Should the policy always be overridden by vision plans or is there a middle ground?
    • What can Bonnie’s doctor do regarding her use of mystery contact lenses?
    • Now that Zack is aware these emails are being sent to patients, should his department treat patients with that insurance plan any differently?

    Expanded Real Deal Responses

    Mina K.
    Brooklyn, NY

    No refund policy should stand. Customer dissatisfaction can always be solved with a redo, exchange, store credit, etc. The doctor should educate the patient that trying inferior contacts is not appropriate for her wear schedule and detrimental/risky to her ocular health. The recommended contacts are the best and can be made more affordable by buying in volume and with rebates. Zack needs to affirm that his services/care rendered are valuable, and personal attention is unmatched by anything bought online by any service or insurance company. This goes for any customer, regardless of insurance.

    Kenneth P.
    Oklahoma City, OK

    Definitely a no-win situation for Second Look Optics. If you don’t give her a refund you look like a jerk, even with the no-refunds policy, but if you give the refund you are losing money because the lab already started the job and potentially will not no-charge the lenses. (Depends on the insurance company and lab, of course.) Since this is a new patient do you risk the blowback from an angry patient and the potential social media lashing? Do you take the time to call the insurance company and say what the heck? Do you explain to the patient that the insurance company is using inferior products to what you are selling hence the price difference? Make very detailed notes that the patient is ordering non-prescribed contact lenses from an online vendor. If the emails are standard policy, there is a need to consider whether to stay with that insurance company, but always try to educate the patient that buying elsewhere means inferior quality for their eyes.

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    Leonard H.
    Downers Grove, IL

    Move to the medical model of eyecare, use the terminology of optometric physican, refer to your practice as an eye clinic, write contact lenses as a prescription and stop trying to sell boxes of contacts, explain up front to patients “your glasses order is being placed as we speak, we will cover any and all issues with our prescription for you for 45 days. We know you will be happy with our eye exam and our optical expertise.” Face it fellow OD’s, we are being attacked from all sides. The old way is gone.

    Rigo L.
    Indio, CA

    I have seen this issue before in slightly different ways and the end result should be in my opinion the same; the office should not take a loss because of the patient finding a “better deal.” An easy way to avoid most of these issues is to always have the patients sign the office policy on returns/refunds. Policies should be included in new patient forms and should be scanned or saved. I have seen policies from no refunds to a 50 percent refund to restocking fees. In an office where the doctors go out of their way to care for patients and open late and on weekends, there is no room for patients that are trying to find “the most affordable pair;” in that case go to chain stores or the other cheap places — some take insurances. Zack should have been firmer with their “no refund” policy. The contacts should have been verified with the doctor before any changes. Not all patients are like Bonnie, so I would keep an eye out with that insurance.

    Cory O.
    Key West, FL

    The vision plan scheme is a zero-sum game for private practices. If you care about the quality of care you provide for your patients, and also want to turn a profit, then you cannot participate in any vision plan. Every day there is another layer of absurdity added to the process by the vision plan companies. This fictional article was only the tip of the iceberg in terms of the day-to-day confusion and problems that arise. Best advice that I have is to discontinue all vision plans or do lots of meditation and double the dose of your blood pressure meds.

    Judith W.
    Orange, CA

    Our policy is displayed throughout our office and printed on all receipts. All sales are final and non-refundable. We have had this happen to us and informed that patient that since the lenses were already in process that we could not cancel the order without charging their credit card for the lenses, since we would have to pay for them. The few times that patients have wanted to change the parameters of the contact lenses to match their wallet we have insisted that they come in for a refit. We explain that their eyes will react differently to each lens material and curve/diameter design and must verify that they will not react adversely to the lens, causing permanent damage. If the patient is not willing to come for the refit, then we will not approve the change and only confirm for what was prescribed. Since this has happened to our office, we do not pull authorization till the day of service and submit immediately once the patient has left.

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    Richard K.
    Castle Rock, CO

    I would write a letter to the insurance company explaining my feelings regarding them stealing my customers and ask to be removed from their network. I know that this reduces exams, but if enough ECPs do this, they may get the message. Unfortunately, it may just be around the corner that the insurance companies offer online refractions and cut out the ECP altogether. Otherwise, a clearly posted significant restocking fee retained on all canceled orders might help. As far as the patient getting different contacts than prescribed by the doctor, I’d at least check the state law and bring it to the attention of the state Attorney General’s office, as well as the FTC.

    Martha D.
    Wheatfield, IN

    Maybe they can match the price her insurance is giving for a new pair of glasses. Match what she would be getting from them and discuss with Bonnie the differences.
    Make a note in her chart and do not give her a prescription for the new contacts. Let her know if she decides to not see the doctor; it is on her, not the doctor for the contacts.
    Maybe call the insurance company in the future when dealing with someone who carries that plan.

    AJ S.
    Houston, TX

    I think it might be time to think about a class action lawsuit against the insurance companies that have this practice. Multilevel practices are destroying independent optical practices. Essilor and China are using the lack of control conditions to hurt rather than help our quality of care. Millennials think that computers can do everything, but they lack the human touch and so will the new generation of future adults. Time, patience, knowledge and personal communication should still matter in any medical situation. Eyecare and eyewear must be important and not be a computer program that is handled through greedy insurance companies that worry about the bottom line rather the human experience.

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