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This Myope’s Broke: How Would Your Office Handle Her?

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SATURDAYS WERE ALWAYS overbooked for Dr. Coakley, who owned a small private practice in a college town. His first patient of the day was ready in an exam chair when he walked in at 8:10 a.m.

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 [email protected]

“Hi Stephanie, nice to meet you, I’m Dr. Coakley,” he said, perching on the stool. She was 20 years old and appeared to be in pain, cupping her left eye gingerly.

“Hi,” she said meekly. “I think I have pink eye or something.”

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Dr. Coakley gently pulled her hand away and saw a very swollen lid. “OK, let’s get started,” he said, pulling the slit lamp over her lap. During the exam he learned Stephanie’s last exam was 14 months ago in her home state. She had cracked a lens in her glasses six months ago, thought she was “about a minus 3” and ordered trendy contact lenses off a Facebook ad. Dr. Coakley noted corneal vascularization and pretty gnarly GPC.

“I am going to prescribe an eye drop. You can’t wear contact lenses until things clear up, and I would like you to come back in two weeks so we can do a complete exam,” Dr. Coakley explained. “I can do a proper contact lens fitting at that time.”

“Do you know what the price is for the drops?” Stephanie asked. “I’m a poor college kid,” she added, with an embarrassed chuckle.

“I don’t, but your insurance should cover a good portion,” he reassured. “I can’t imagine it being more than $20.”

Stephanie checked out at the front desk and called her mom for a credit card number for the $60 specialist co-pay.

Later that week Dr. Coakley’s staff obtained a faxed copy of Stephanie’s chart from her regular doctor. There was no indication of a contact lens fitting, nor mention of an online verification request, but the receptionist did mention a $340 outstanding balance.

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At her next appointment the technician pretested Stephanie and made note that she was still wearing a contact lens in her right eye.

The first thing Dr. Coakley did was evert her lids. “When was the last time you used the eye drops?” he asked.

“I didn’t end up going to the pharmacy,” she admitted sheepishly. “My roommate had some Visine — that’s definitely made my eyes feel better.”

“Unfortunately your eyes are still sick, so we need to reschedule again. I need you to go without contacts in both eyes for a while and use the drops. These contact lenses are not fitting you well and they frankly may not even be the right prescription, so I would recommend throwing them out as soon as you get home so we can start over.”

“I don’t get it,” she said, defensive. “I gave the contact lens company my other doctor’s info and they said they’d confirm everything. I got the contacts… so someone must have checked my records and approved it.”

“There was no indication the office was notified of your order,” he replied. “To be honest, that doesn’t surprise me. The internet is the Wild West.”

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She groaned. “My regular exam is covered by insurance but since we aren’t doing it today do I have to pay another $60?”  Dr. Coakley nodded. “Great. I shouldn’t have come back,” she muttered.

Dr. Coakley escorted Stephanie to check out, but at the front desk she had one more question.

“Now that you have my records from my old doctor, can you give me the glasses prescription she wrote?” she said, holding her broken glasses.

The Big Questions

  • Is there anything you would have done differently if you were Stephanie’s doctor in this case?
  • Have you ever dismissed a patient for not complying with a treatment plan? How about using contact lenses without a prescription?
  • Would you give a patient a faxed copy of an outside prescription? Why or why not?
Nancy C.
Cortland, NY

No, I would not provide a copy of another doctor’s Rx. I would instruct the patient that information needs to be provided by them. I would explain to the patient there was no CL Rx to verify or fill. The CL she is wearing was not prescribed and is equivalent to street drugs—a crapshoot. I would review proper procedures for exams, CL fitting and follow-ups, and have it in writing to have signed as understood. Then I would explain that I cannot provide services, nor will ever, as noncompliance and disregard has been the obvious choice of conduct. I would not be willing to accept responsibility for such a patient. I would provide a list of providers in the area, smile and wish her luck.

Angel M.
Cynthiana, KY

Stephanie’s previous office did nothing wrong; they faxed everything Dr. Coakley would need to start the fit. They definitely were in the right, alerting his office that she was a bad debt. Most noncompliant patients tend to dismiss themselves when they don’t like what the doctor tells them! Just make sure you document, document, document everything — and I mean everything. And giving a patient someone else’s faxed Rx, especially when they are a bad debt and have no history of contact lenses, etc., is beyond the pale of professional courtesy and could land Coakley’s office in hot water — considering she had never had a contact fit — if she re-orders sub-par contacts again and has permanent damage as a result. I’d tell noncompliant grifter Stephanie that she needs to call her doctor for a copy, and document, document, document. PS: Did I mention to document everything?

Nina C.
North Chesterfield, VA

I would not write a prescription from another doctor’s faxed record. I would charge her for a refraction so she has an updated glasses Rx, so she can discontinue contact lens wear and also for the specialist copayment.

Jenna S.
Fargo, ND

If she was a bunny hill skier who went down a black diamond slope and broke her leg, she wouldn’t think twice about paying for follow-ups and following the doctor’s instructions. The doctor needs to have a real serious talk and let her know what the long-term implications can be to her vision and her life. I would not release her Rx to her from another doctor — it wouldn’t be mine to release. She needs to talk to them about that. I would consider filling it in my office but she would need to pay for it before the order, since she has a history. I would have our opticians try to repair her frame, even if it is with superglue and tape, especially if it means she throws those contacts away before she ever leaves the office.

Martha D.
Wheatfield, IN

Unfortunately, we have run into this situation too often. When we do, the doctor will always try and advise the patient on the best course of action. If the patient is non-compliant then he’ll refer them to an ophthalmologist for further review. He will prescribe glasses to get them by until the eye is completely healed. The glasses would probably have to be changed a couple of times. The doctor would release a patient from his care if they were noncompliant. We did have a patient once who would sleep in his contacts all the time, get eye infections and end up in the emergency room. He quit coming to see us because we “nagged him” about his over-wear of contacts.

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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