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Real Deal

A Small Practice, a Deaf Patient, an ASL Translator Paid For … What Happens When the Patient Cancels?

A request for ASL translation shakes up this small office. Does the practice have any options?

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SANGAMON VISION SERVICES, an efficient office of one optometrist and two employees, was situated near the capital city of Springfield, IL. One day a man called to schedule an appointment for his son … with an unexpected request.

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
  • “My son is deaf and will need a professional translator,” explained the man briskly.

    Receptionist April paused to process the request and stumbled on her words. “Oh, uh, well, we don’t have any one at the office who knows sign language,” she explained, “is there something on the internet saying we offer–”

    The man interrupted her. “No. It’s a requirement, under the Americans with Disabilities Act.”

    April quickly asked if he would hold, and went to find the optometrist, Dr. Simms. “The patient is a deaf child, and his father is going to be in the exam with him,” she explained, handing the receiver to him. “He is requesting an interpreter.”

    Dr. Simms took the phone and greeted the patient. “I’ve examined deaf patients before,” said the doctor, “we don’t need an interpreter, I have a system that works well.”

    “That’s all well and good, but for medical visits I need someone fluent in ASL,” replied the father. “I have the phone number of a local service if you want it?”

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    The doctor cleared his throat and said, “Okay, give the receptionist the number and we’ll make it happen.”

    April made the call and was told a translator would come to the office for a two hour minimum, at $150. The translator also reminded April that the office was responsible for the fee, not the patient. 

    The appointment was scheduled for the following Friday, first thing in the morning. As the translator found a seat in reception, April checked the voicemail. She found a message from the patient’s father asking to reschedule. Dr. Simms called the patient’s father himself.

    “My son is physically getting sick and needs to stay home, so we need to reschedule for another day,” the man explained. 

    “That’s fine, but we did pay the translator $150 to come today,” said Dr. Simms. “Would you please contribute to that balance before we reschedule you?”

    “This service is supposed to be covered by the office!” said the man. “Besides, I did call and cancel.”

    “According to the machine, we got the message at 9pm last night, so we weren’t able to reschedule the translator,” continued Dr. Simms. “Even if you covered half, that will make me feel better that this won’t happen a second time.”

    “Absolutely not!” he said.

    “Then I’ll be happy to refer you to a colleague locally, but as a small office I just can’t help you. Maybe a larger practice will have better resources,” said Dr. Simms.

     

    The Big Questions

    • Is there anything April and Dr. Simms should have done differently prior to the appointment?
    • Should the patient be expected to incur a penalty for no-showing? What if it happens a second time?
    • Is it ethical and fair for Dr. Simms to refer this patient to a larger practice?
     

    Expanded Real Deal Responses

    DJ S. Pinson, AL

    The law is the law and unfortunately there’s nothing you can do but factor the cost of those appointments. Be very careful with how you handle such appointments and make sure you get the translator to fill out a W-9 form because that fee you pay is tax deductible. Also, offices large and small need to understand that when that person does come in the office, you and your staff need to speak directly to the patient (not the translator) during all services, from the exam room to the sales desk. It’s up to the translator to follow along and convey your message to the patient.

    You have to operate like the patient doesn’t have a disability even though it’s covered by the Disability Act. These appointments have worked well for us in the past. The translator sees whether you truly care and will recommend other deaf patients to your office. Embrace and love on them and the profits will come.

    Dr. Tex S. Citrus Heights, CA

    On the initial call I would have told the father I will find an eye doctor that is proficient in ASL. Several years ago, I needed an ophthalmologist that could sign in Italian. I found such a doctor and the patient had cataract surgery. It all worked out OK.

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    Pam P. Downers Grove, IL
    1. If you currently have a cancellation fee policy that was established with the patient, then charging the patient for the cancellation would be appropriate.
    2. If the patient is insisting and the doctor has additional patients that could benefit from the service, perhaps a “signing” day or two would be beneficial to the doctor and the community.
    3. I believe there is a tax credit for this paid service. The service is paid at this point whether the patient is seen or not. Make a note for your accountant!
    Tim S. Philadelphia, PA

    Directly from ADA.gov: “For people who are deaf, have hearing loss, or are deaf-blind, this includes providing a qualified note taker; a qualified sign language interpreter, oral interpreter, cued-speech interpreter, or tactile interpreter; real-time captioning; written materials; or a printed script of a stock speech (such as given on a museum or historic house tour). A “qualified” interpreter means someone who is able to interpret effectively, accurately, and impartially, both receptively (i.e., understanding what the person with the disability is saying) and expressively (i.e., having the skill needed to convey information back to that person) using any necessary specialized vocabulary.” I take this to mean that it is sufficient that the OD already has a tried and true method of communicating with the deaf. Being armed with this information would drastically change the tone of the conversation with the patient’s father.

    Adele P. Jacksonville, FL

    The patient’s health insurance may cover the cost of the interpreter. It did so for me and it was a Medicaid HMO.

    Casimiro G., MD Los Angeles, CA

    I would not have gotten an interpreter and referred him to another practice, since this is too much of a financial burden for my small practice. If I had been able to communicate with this patient using my system for the deaf for the refraction, then the parent should be happy with my effort and not insist on a certified ASL translator, unless he provides one.

    Lynette M. Loveland, CO

    Interesting that the dad was so pushy. It seems to me that the office went out of their way to work with them, incurring a cost that is not going to be covered by anyone. At this point, it seems that referring the patient elsewhere would be mutually beneficial. The dad is not being reasonable; at the same time, I am sure he struggles in his own situation. For the office to recommend a facility that is better equipped to meet their needs, as well as some accountability on dad’s part in terms of “this is not working for our office” seems more than reasonable and best for both parties. The reality is that not every office is a perfect fit for every patient.

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    Gail R S. Chesapeake, VA
    1. They should inform the customer they needed 48 hours in advance notice to cancel the appointment since prior accommodations were made for his son’s visit and that a penalty will occur if they cancel short notice of $150.00 or half $75.00.
    2. Yes, because the accommodations were made there would not be a second time cause the patient will be informed.
    3. Yes, it was fair because they tried to accommodate the patient and could not accommodate him any longer because the father is not being reasonable.
    Jen Arlington, TX

    I think they should have checked with his medical insurance to see if an interpreter is covered for the office visit. Also check the guidelines of the act. The patient should incur a no-show fee. It is ethical for Dr. Simms to refer the patient out.

    David F. Colorado Springs, CO

    We see a lot of deaf patients. I simply ask that they have a referral from an agency that is willing to help. Here in Colorado Springs there are many willing to help.

     

    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 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.

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

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

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

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    ABOUT REAL DEAL

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

    ABOUT THE AUTHOR

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    The Big Questions

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

    Expanded Real Deal Responses

    Mona D. Fort Wayne, IN

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

    Jen H. Sandpoint, ID

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

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    Leisa S. Newport Beach, CA

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

    Chani M.  Highland Park, NJ

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

    Pam P. Downers Grove, IL

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

    Jamie L. Bradenton, FL

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

    Ann H. Sturgeon Bay, WI

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

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    Rick R. Girard, PA

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

    Robert M. Edina, MN

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

    Nikki G. Oakdale MN

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

    Jennifer L. Dansville, NY

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

    Michael D.  Eldersburg, MD

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

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