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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.




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

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.

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


    “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.

    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.

    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.


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