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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

    The Case of the Online Poachers

    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.

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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

    “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 Patient Pushes an Optician to Bend the Rules. Is This A Gray Area Or Are They Committing Fraud?

    The case of the fraudulent filing.

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    COLIN WAS STRESSED. His coworker had called out an hour before her shift, leaving him to run the optical floor solo. Two patients were already moving through the frame boards when a tech escorted Dr. Tam out of an exam room and over to Colin.

    ABOUT REAL DEAL

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

    ABOUT THE AUTHOR

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

    Dr. Tam was a local general practitioner. Colin was relatively new to the Utah practice but he had already met Dr. Tam during his son’s eye exam.

    “Nice to see you again,” said Colin, pumping the doctor’s hand. “Did your prescription change?”

    “My reading power is being bumped up,” said Dr. Tam amicably. “I’ll get new progressives; you have my insurance information?”

    “I do! I’m working with a few other people, but I’ll do my best to get you out of here quickly,” promised Colin. “I’ve got five frames pulled for you to start, see what you think and I’ll be right back.” After checking in with the first two patients, Colin bounded over to the reception station and pulled benefit printouts from Dr. Tam’s chart. When he came back Dr. Tam was already seated at an optical station.

    “I like these,” he said, clasping one of the pairs Colin had selected, “and I want to order these Maui Jim sunglasses under my son Richard’s insurance plan. Do you remember him? He was in last month.”

    Colin sat across from Dr. Tam and used a nearby laptop to look up the boy’s information. “It looks like he wasn’t given a prescription at his exam. Your insurance plan has a minimum prescription requirement to pay for the sunglasses,” Colin explained.

    “Oh, that’s right,” said Dr. Tam, reaching into his breast pocket. He pulled out a prescription pad and, in front of Colin, wrote out a prescription for his son. “It needs to be a half-diopter, right?”

    Colin nodded numbly, and awkwardly took the script when Dr. Tam handed it to him. “I need to take his measurements…”

    “Just use what you have from last year,” said Dr. Tam. “It’s tough to get him in, between everyone’s busy schedules.” Sure enough, Colin found an entry in the EHR for another pair of Maui Jim sunglasses. Colin priced out the orders, took measurements and escorted Dr. Tam to reception to collect his copays.

    Later that afternoon Colin found time to enter Dr. Tam’s orders. However, when he entered the authorization number that the front desk had pulled he found it was actually for Dr. Tam’s son – Richard Tam Jr. Dr. Tam’s benefit wasn’t available until the first of next month.

    Colin immediately called the number on file for Dr. Tam. His wife answered their home’s landline and Colin explained the situation. “I can hold the order for three weeks and then process the exact day his benefit resets?” Colin offered.

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    “No, no,” said Mrs. Tam. “He’s been complaining for weeks, I don’t want to delay. I’ll just give you my credit card.”

    Colin rushed the two orders but it was weeks before Dr. Tam finally came back for his dispense.

    “Oh, these are great!” said Dr. Tam enthusiastically, studying the near vision card with his new progressives.

    Colin beamed. “Did you bring your son? I was going to adjust his sunglasses for him.”

    Dr. Tam chuckled. “Well, they’re really for me,” he shared. “Of course I’ll share them with him if he wants, but I need them when I’m wearing my contact lenses, and I lost last year’s pair.”

    “Ah,” Colin nodded. “And I assume your wife told you she ended up paying for your glasses since you weren’t eligible?”

    “Yes, it reset this past Monday, right?” asked Dr. Tam. “Just give me the invoice with Monday’s date and I’ll submit it.”

    “I don’t think we’re allowed to change the date,” said Colin. “Technically the insurance company considers that fraud.”

    Dr. Tam scoffed. “If anyone gives you a hard time, you just have them call me,” he replied.

    The Big Questions

    • If you were Colin, would you have done anything differently when discovering Dr. Tam’s eligibility was incorrect?
    • Assuming Colin is physically able to revise the EHR to date the order to the first of the month, should he provide the invoice for Dr. Tam to submit his claim?
    • Would you dispense the sunglasses, or return them, accept the loss, and report Dr. Tam for fraud?

     

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    Maureen G. Oak Park, IL

    Didn’t Colin look at the name on the benefit sheet?! And seriously who would order anything based on a script a patient wrote out? I would have said, “I am sorry I need a valid doctor Rx, otherwise it’s not valid and I can lose my job over it.” We always have the sheet printed out with the patient’s name and benefits eligible highlighted. Colin sounds like a pushover; we have had patients who want to use their frame benefit for plano sunglasses and our answer is always, “No, that’s committing fraud.” I can’t believe any ethical optometrist would endanger his practice by agreeing to do this.

    Rigo L. Indio, CA

    Let me start by saying we all “bend” the rules from time to time for some of our “VIP” patients. That being said there is a line to draw when bending the rules becomes fraud or feels wrong. As opticians we feel that any professional that walks into our office will always do the right thing. So when doctor Tam wrote an Rx for his son I would have told him that I didn’t feel comfortable filling the Rx, even though I knew what he was doing, and that I would rather talk it over with our doctor. At this point he would have to understand that something smelled fishy. When he asked to change the date, I would be frank with him and just say that I would not feel right doing that. If you bend the rules one time the patient expects the same the following year. Sometimes it’s just best not to do things, no matter who the patient is.

    Peter N. Belfast, ME

    This case is not uncommon. The simple answer to somebody who asks you to lie to the insurance company is: “Do you want me to lie to you?” The answer is usually, “No.” Then you can say, “I’m not going to lie to your insurance company either.”

    Lynn M. Fallston, MD

    1) I would have done the exact same thing with the eligibility date. If the patient’s wife chose to pay I would take payment and proceed with the order.
    2) I would NOT change the date in our EHR to facilitate insurance fraud. Not happening!!
    3) I wouldn’t dispense the glasses…BUT it never would’ve gotten that far because….I never would’ve taken the Rx from a GP to begin with. Is that even legal??

    Preet K. New York, NY

    I’d explain to Dr. Tam that the practice can get audited at any given time, and this is considered insurance fraud. I would offer a discount on a second pair. Colin should not have accepted the Rx written by Dr. Tam as it is an unethical action taken by Dr. Tam. If the doctor who examined Tam Jr. didn’t prescribe any Rx, Colin should follow that. Ask Dr. Tam to reach out to the insurance to find his options to process the sunglasses order or offer to make the phone call on Dr. Tam’s behalf. (This shows customer service.) If Dr. Tam is uncooperative, call the insurance and inform them about Dr. Tam writing the Rx for Tam Jr. Colin shouldn’t change the DOS for the private-pay order even if the EHR system gives him the ability to. Have the patient discuss this with his insurance as well. I wouldn’t recommend processing the sunglasses order unless Dr. Tam follows the right steps. Document everything. Have Dr. Tam sign a liability form, which protects the practice from auditing.

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    Kate G. Arlington, VA

    Fraud is fraud. Why sully your reputation?

    Amelia B. Charleston, SC

    Insurance fraud is any act committed to defraud an insurance process. This occurs when a claimant attempts to obtain some benefit or advantage they are not entitled to, or when an insurer knowingly denies some benefit that is due.

    Theresa W. Austin, TX

    Graciously, the optician should have advised the patient that the prescribing physician had not provided a script for his son, so unfortunately the sunglasses would not be covered by insurance. The optician then should ask, “How do you wish to proceed?” There can never be an exception for fraud.

    Daniel M. Rockaway, NY

    Of course he should not do any of those things. It is considered fraud and he risks at least his participation in the plan if not the license of the practitioner itself.

    Genna L. Milwaukee, WI

    Colin did the right thing by attempting to contact Dr. Tam. However, it’s important to speak directly with the patient when they’re responsible for their own care. Speaking with Dr. Tam would’ve given Colin an opportunity to assertively avoid possible fraud and any consequences of it. It would’ve been 100 percent wrong for Colin to modify the invoice date to comply with Dr. Tam’s request. Had the claim been audited, the insurance company would’ve found evidence of fraud in everything from the copay dates to material order dates. Dr. Tam, as a medical practitioner, is required to acknowledge that he understands insurance fraud and its consequences, and as such he should not be instructing other health care providers to commit fraud on his behalf. Were I in Colin’s situation, I would suspect Dr. Tam of committing fraud at his own practice, and would absolutely report Dr. Tam and accept a loss on the materials I ordered, knowing that I did the right thing.

    Judy C. Virginia Beach, VA

    1) Colin did the right thing by calling immediately when the issue arose.
    2) NO! Changing dates on a receipt or in patient records is fraud. This is not a “gray area” in my opinion. Unless the offending doctor owns the insurance company, he doesn’t have any clout with them either.
    3) Dispense the eyewear and note the conversation in his record. I would also make the practice owner aware of what his patient requested and that he stated that it was done for him in the past at the practice. Let the doctors discuss the issue. Neither Colin nor any other staff members should have to be caught in the middle of this.

    Stewart G. San Francisco, CA

    1) NO
    2) NO
    3) I would make him pay for them—nothing more, nothing less. If he refused, I’d send him to collection, AND I’d dismiss him as a patient.

    Taylor K. Ellington, CT

    1) Colin handled the situation appropriately when he discovered the eligibility issue—he called the patient immediately. HOWEVER, the first issue really arose when the patient wrote his own prescription. We would not have filled the Rx, as it was not valid. Regardless, Colin should have accepted the wife’s credit card for the full charge amount without insurance and continued with the job.
    2) I would assume most systems, like ours, allow for date change on the invoice. However, of course, this is fraud and Colin should not do this.
    3) I would have dispensed the sunglasses, as they should have already been paid for in full by the wife. I would advise Dr. Tam he can do what he wishes with the invoices, but that the office cannot and will not change any posting dates as it is fraud.

    Bob S. St. Louis, MO

    I wonder if Dr. Tam is as loose with insurance policy in his office as he expects Colin to be. While technically he did nothing illegal by writing an Rx for his son, it was an ethically reprehensible thing for a healthcare professional to do. Even worse, he expected Colin to risk his job and the reputation of his company by performing an illegal act. Again, I wonder if it is a standard operating procedure to falsify records in HIS office. If I remember nothing else from optometry school, one thing will be forever ingrained in my mind: “Never change a record. Put a line through the original information, insert the correction, initial and date it.” It’s a digital world now but the advice is still as relevant as in the good old (paper) days.

    Leisa L. Newport Beach, CA

    Dr. Tam’s eligibility should have been checked before the order was taken for his new glasses. However, since Colin notified Dr. Tam indirectly through his wife the order became a private order and was paid accordingly. The receipt date should not be changed to appease Dr. Tam. In regard to dispensing the Maui Jim sunglasses, Colin submitted the order with the proper Rx information provided for Dr. Tam’s son Richard with the required measurements from Richard’s chart. Technically it should be said that Richard is sharing the glasses with his father, not the other way around. This is one of those areas that is stretching the system by Dr. Tam; Colin was following the Rx provided by Dr. Tam for his son.

    Judith W. Orange, CA

    No, we do not change invoice dates; that is fraud plain and simple and no patient is worth the legal problems. As far as notifying the patient of his options of waiting till the first of the month or paying for the glasses, that is our standard policy. As far as making glasses without having a proper written prescription—either our own (from records) or from another OD or OMD—we would not do it. We do not feel that a primary MD can give a complete comprehensive eye exam, especially if he is just writing out what is necessary for insurance coverage

    Jennifer Torrance, CA

    I would have discussed all this with management first to see what options they wanted me to proceed with. If those options comprised my morals or ethics, I would then proceed to remind management that we have an obligation to not just the patients but to the practice and employees to make sure we have a secure livelihood by following the rules. If we continue to bend the rules, we will go down a path of no return and will be held hostage by patients that know we shouldn’t be doing this.

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

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    Real Deal

    A Difficult Teenager, Absent Parents and Unacceptable Behavior … Kick the Kid Out or No?

    This office wants to show a pre-teen the door – should mitigating circumstances change their minds?

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    IT WAS LATE MORNING and patient care was in full swing at a large optometry practice in Detroit. Doctors and technicians hustled patients between rooms, and the phone rang incessantly.

    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

    Technician Carol headed to reception to call in the next patient, 15-year-old Jennie. “Do you have a parent with you?” asked Carol, scanning the room. “My dad dropped me off,” she replied flatly. “It’s fine.” Carol shrugged and led Jennie to pretest. She began reciting her script of instructions, but Jennie threw her off quickly. “Is this the puff of air?” she asked dramatically. “No,” said Carol, “like I just said, it’s an auto refractor, it’s just a picture. Nothing is going to touch you.” Jennie was clearly skeptical, and kept pulling her head away from the forehead rest. Carol worked hard to convince Jennie to keep her head still, but only captured one good reading in each eye. She didn’t bother asking Jennie to use the non-contact tonometer, and escorted her straight to an exam room. That’s when Carol’s challenges really began.

    Jennie refused to disclose her health history or medications, left the room twice to use the restroom, and repeatedly challenged Carol’s competency. Twenty-five minutes later Carol still hadn’t completed Jennie’s work-up. Saying she needed something from another room, Carol found a quiet place down the hall and took a minute to collect herself. When she returned, she immediately noticed the 90D and 20D lenses were missing from their regular places. She wrapped up the exam and found office manager Ed. “I think my patient is trying to steal from the exam room,” she whispered. Ed frowned and followed her into the exam room. “Hi Jennie, I’m Ed the manager,” he said, standing in the doorway. “Can you please check your pockets and backpack for anything that might belong to our doctors?” Jennie scoffed, her neck and arms erupting in hives. Time seemed to stand still. “Screw you!” she eventually yelled at Carol, who threw her arms up in exasperation. The exchange drew Dr. Cox out of her exam room. “What’s going on?” she asked Ed. As she neared, something hard struck the back of her hand. She yelped in pain as a 90D lens hit the floor then rolled fast along the baseboard. Dr. Cox looked up to see Jennie palming the 20D, a look of shock on her face. “I didn’t mean to hit you!” she said, clearly scowling at Carol. Panicking, she dropped the lens and grabbed her coat. “Move,” she said, and Ed finally cleared the doorway. Jennie flew around the corner and out the front door.

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    Dr. Cox motioned Ed and Carol into the empty room and closed the door. First Carol, then Ed recounted the last half hour’s events, concluding with the same thought: “We have to fire her from the practice!”  Dr. Cox, gingerly massaging her hand, raised her eyes to the ceiling. “Jennie’s mom is my husbands’ boss,” she said slowly. “I am going to make a call after I get back on schedule, and we will figure this out.”

    Hours later, Dr. Cox’s cell phone received a voicemail from Jennie’s mother. She explained how Jennie’s behavior over the last few months had been worrisome, and they were receiving assistance from a psychologist in addition to the pediatrician. She begged Dr. Cox to let Jennie return the next day to complete her exam, and promised to attend with her daughter.

    The Big Questions

    • What considerations should a practice have when dismissing someone under 18 years old?
    • If Dr. Cox decides to allow Jennie back, the staff won’t be pleased. Is there a way to mitigate this?
    • At what point did Jennie cross the line, based on your office’s culture? Would you allow her to return?

    Expanded Real Deal Responses

    Judy C. Virginia Beach, VA

    The first problem was allowing an underage child to be seen without a parent or guardian in attendance. That’s should never be allowed. Additionally, I don’t see dismissing an underage patient without a consultation with the responsible adults. The staff may not be pleased, but that should not affect their professional performance. If it does, there is a bigger problem to be addressed. Jennie crossed the line when she refused to participate in the pre-test workup and she should only be allowed to return with a parent or guardian.

    Stewart G. San Francisco, CA

    Why was this patient seen without a legal aged family member? The patient should have been kept in the waiting room until the adult relation arrived and could be present during testing. This child is a thief. She could have also declared that the staff touched her inappropriately causing a lawsuit and a ruined career.

    Dennis I. Monroe, CT

    Our office is very specific towards seeing unaccompanied minors. NO! If it is a new patient; definitely not! If a new patient’s parent insists, then we discuss the nature of liability in these situations. That usually ends with the parent making the appointment when they are available. If it’s a patient that the office is familiar with, there may be exceptions, but the answer is most often if not always: NO. There is too much that we as physicians are responsible for and parents need to be… Parents. There is too much at stake to see an unaccompanied minor.

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    Donna R. Mission, BC, Canada

    I once had a patient threaten to punch me when I did the NCT on her. She yelled at me loud enough for the doctor to come out. She quickly tried apologizing and said I scared her. He opened the door to the office and said he would happily send her file to any other doctor she wanted. If you know your child is having issues then you make arrangements to accompany them to appointments. There is no excuse for theft. As for the husband’s boss connection, that’s an employee standards issues if they take it out on you.

    Kinga B. St.Catharines, ON, Canada

    Really the issue here is that she has behavioral issues, and I don’t think they would magically go away at 18, only the legal issues change. There should be a policy that minors of any age can be seen alone provided they can BEHAVE like an adult. The conversation should be had with the person booking the appointment at the time of the appointment and if not, then at the time of the reminder call. Perhaps an email of expected behavior could be sent to the parent or student, or simply stated that any behavior not allowed at school is also not allowed at the optometrist’s office. And it should outline the concentration they are expected to have so the exam can proceed. There should be an open door or 3rd party policy to prevent the allegations of sexual abuse also. The first time any child or teen shows up there could be a behavior agreement they have to sign. Most kids are fine but with the high rates of autism/Asperger’s and general behavioral issues, and the large number of frazzled parents who can’t take the time to accompany their kids, there has to be a line in the sand and the office needs to set expectations.

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    Erin J. (From Facebook)

    Bye, Jennie! The lip I could look past, and would let her come back with a parent at our earliest opening (usually about two weeks out). However… the thieving and assault on my staff? No. That behavior would get you banned from any business, and possibly charged. My business is no exception.

    Rick R. Girard, PA

    1. Why would the parents let her come alone knowing she had problems? There is a parental issue to deal with. 2. It’s Dr. Cox’s office so I don’t think the staff should be upset. If they are that’s another issue. It’s not like Jennie threatened violence. 3. She crossed the line by stealing. Whether she can return should be based on all available info and Dr. Cox’s decision. Because I sometimes stupidly believe the best in people, I would allow her to return.

    Dr. Texas S. Citrus Heights, California

    No minor should be examined without another adult present—ever! I would do the pre-screen myself on the next visit. During the exam I’d show her what bio lenses are for. I’d dilate her mom, put the bio on Jennie and have her look into her mom’s eye. I’d ask Jennie if she had questions and be sure she leaves with pens, a makeup mirror, and eyeball keychain, but not my bio lenses or lens clock (I’ve lost three in 50 years). If Jennie needs an Rx, have your most tech-savvy optician take pictures during frame selection. If she balks at these, drop it.

    What’s the Brain Squad?

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

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