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Patients Are Upset About Unexpected Out-of-Pocket Costs. Who’s to Blame?

Does responsibility lie with the patient, the doctor, or the billing department?




MARY, I DO not know what to do with Dr. Brighton. She is such a good doctor, and patients love her, but the way she bills exams has me pulling my hair out,” said Nancy, the billing specialist.


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.


Carissa Dunphy has been working in private practice optometry since 2008 and is the founder of Optician Now ( Follow Carissa on Instagram and Facebook at @opticiannow.

“I know she means well,” Mary said. “Is she still not being clear with patients about their visits?”

“Judging by the number of patients who call and complain about their bill, I’m guessing not,” Nancy replied.

“What should be happening so the patients don’t call mad about having a bill?” Mary said.

“How it goes is the patient comes in for their yearly eye exam expecting a $10 copay using their vision plan. Easy and simple.” Nancy continued,
“How it ends is the patient has some applicable medical diagnosis, allowing the visit to be billed to their medical insurance, rather than to their routine vision plan.”

Mary replied, “So why is there a bill?”


“Many people haven’t met their deductible — especially in a new year — or their plan only pays for a percentage of any office call, and we’re a specialist so their copay is often higher as well,” Nancy answered.

“Isn’t that somewhat the patient’s responsibility?” asked Mary. “How are we supposed to know all of this with all of the different insurance plans out there?”

“I mean, ultimately, yes.” Nancy added, “But don’t you think it would be a common courtesy for Dr. Brighton to have a small spiel saying something to the point that we are not using your vision plan today and will be using your medical, in case they have a deductible. Maybe even ask if they understand or if that is OK with them.”

“Ideally that would be great, but I’m sure the patient would have questions about their insurance.” Mary concluded, “And what if they said no because of the deductible and then they wouldn’t get their important medical testing done!”

“I know. That’s why it’s such a teeter-totter thing.” Nancy added, “I just don’t think it’s fair that, one, the patient has an unexpected bill, and two, that I am the one having to talk to them about their unexpected bill that they’re pissed about.”

“Yes, that is a conundrum.” Mary continued, “I wonder if we get paid more for medical visits. Or perhaps Dr. Brighton is just trying to avoid the whole conversation because it’s like opening a can of worms.”

Nancy sighed, “I don’t know how other offices do it, but we have got to figure something out. We’re going to drive patients away. And I don’t get paid enough to deal with the angry ones with a bill.”

The Big Questions

  • Would you consider this part of Nancy’s job? And should the office keep doing what they’re doing with the knowledge that they may lose her?
  • Does the unexpectedness of the out-of-pocket costs lie with the doctor poorly explaining things or with the patient not understanding their own plan?
  • Should Nancy just have the doctor deal with the angry people with an unexpected bill?


Maggie C.
Winston Salem, NC

We like to be as transparent and honest with our patients as possible. Sometimes that means we don’t know up front when booking their appointment that we may need to bill it to their medical insurance. In the event that what started out as an annual comprehensive exam switches gears mid-exam, the responsibility lies with our eye doc to let the patient know that it has become a medical visit and will be billed as such.

That being said it is not our OD’s responsibility to know the ins and outs of each person’s insurance and sometimes that is the responsibility of the optician checking the patient out. We oftentimes say, “We will bill the entire visit to your medical insurance. Sometimes they bounce a portion of the bill back and at that point you will be responsible for payment.” Folks are sometimes upset about this or forget that conversation when a bill arrives in their mailbox and at that point we let them know their health is the most important thing to us.

Kandi M.
Gig Harbor, WA

Constant battle every day. I blame offices/doctors that provide medical care at vision exams, which is fraud. You see it, you discuss it, you diagnose it, you manage it, you Rx it, you refer it, you report it, then you must add that medical diagnosis and your exam complexity has increased and it is not a routine vision visit.

Explain upon check-in why the visit may be billed to medical, have forms the patients read and sign. Why do we have to suffer? No other profession would give away their services like optometry does. It’s very sad that offices take the easy way out just to keep the patient happy, or to not piss off the overlord, and remember it is fraud, pure and simple. Blame the insurance company for your billing; you are just following their rules.

Martha D.
Wheatfield, IN

I believe the responsibility lies with the patient or POA. However, unfortunately we live in a society where it is becoming more and more the doctor’s office staff or the optical shop staff to know what is covered and what is not. We used to print out the benefits with the authorization and show it to the patients. We also had great doctors who would also try and explain to the patients what is covered by what. If we work together with the patients or POA it makes a much better relationship for our patients.

Jennifer H.
Sandpoint, ID

Ugh, not fun. You know how to fix it? STOP CONTRACTING WITH VISION PLANS. Until big insurance is willing to partner up and help us fix hiccups in the industry, we don’t need them. Our office is celebrating 10 years without this dilemma in 2023! Price your services and products appropriately, and customers will come to you anyways (and be much happier too).

Morgan D.
Carmi, IL

It’s the billing specialist’s job to explain how visits will be billed and the doctor’s responsibility to be the doctor. Having that conversation in the exam lane seems inappropriate.

If patients have medical insurance, they should be responsible and learn the ins and outs of it on their own. Grown-ups have to do grown up things! Go to appointments expecting to pay when you’re there and/or expect a bill later on. It’s part of life and having insurance.

Absolutely not. The doctor did their job, the billing specialist should do hers/his. We’re a team and roles should be clearly defined for each team member!

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