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Real Deal

What Would You Do If You Were This Office Manager Who Caught Her Doctor and Optician in a Sneaky Sun Swap?

Rx lenses are made but they never get dispensed so that a plano sun gets covered by insurance.

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WEST VIRGINIA’S BALFORD Vision Center had recently hired their first practice manager, Ellen. She moved to town specifically for the opportunity, bringing nearly 20 years’ experience. The small staff was eager to impress, yet anxious at the prospect of Ellen exposing various flaws and inadequacies.

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]

One day Ellen was covering the lab while optician Leslie took her lunch break. A patient arrived for an eyewear dispense, and Ellen reviewed his tray: a sporty, wrapped frame with G-15 polarized lenses. Ellen also found a baggie containing an additional set of heavy, clear lenses.

She checked both pairs in the lensometer and popped back out to see the patient.

“Sir, I just need another moment. Your glasses are here but I need to insert your prescription lenses into the frame,” she said with a smile.

“No, no, I don’t want the prescription,” he replied. “The other person said she was going to give me the plain lenses so I’d have sunglasses to wear over my contact lenses.”

Ellen cocked her head to one side. “Strange. I wonder why she made you lenses,” she said quietly. “Well, I will go get your sunglasses for you!”

Ellen spent some time adjusting the man’s frame and once more confirmed he didn’t want his prescription lenses. As he stepped out, Leslie walked in.

“Hey!” said Ellen amiably. “Can I ask you about that guy’s order?”

“Sure, what’s up?”

Ellen grabbed his tray and started rifling through it. “Why did you order prescription lenses, but not dispense them? He told me he just wanted the demo sunglass lenses.”

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“He wanted to use his vision plan,” explained Leslie.

“Oh,” said Ellen, and paused. “I guess I don’t understand.”

“Well, they don’t allow patients to buy plano sunglasses, so I just order a pair of lenses that are completely covered or just have the minimum copay, then swap the lenses out when they come back from the lab and throw them away,” she said matter-of-factly. “If they have a co-pay, we deduct that from the frame copay so they aren’t paying anything extra. Patients are fine with waiting, as long as they can use their plan.”

Ellen nodded slowly. “Is that what the doctor wants, or is that your own workaround?”

“Yeah, Dr. Balford told me to do it that way,” said Leslie.

Ellen sat down with the practice owner a few hours later to explain the situation and her concerns.

“We can’t order lenses with no intention of dispensing them,” explained Ellen.

Dr. Balford shook his head. “I don’t remember ever discussing this,” he confessed. “But it seems silly not to be able to give the demo lenses to a patient — it should be considered a part of the frame purchase!”

“If we get audited, there’s a risk our contract will get canceled,” warned Ellen.

“That’s a big ‘if,’ Ellen.”

“You have also encouraged an employee to commit insurance fraud. I reviewed our records for the last 12 months and I see 20 instances of Leslie processing fake lens orders,” she said. “We need to take action of some kind.”

Dr. Balford shrugged his shoulders. “I feel like this is a gray area — I’m not convinced we should change anything.”

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The Big Questions

  • Do you agree with Dr. Balford that demo lenses should be included as part of the frame purchase?
  • How do you protect the business if it gets audited by the vision plan in question?
  • If you were in Ellen’s position and Dr. Balford elected to continue this policy, what would you do?
Jess G.
Leesville, LA

Patients are responsible for any eyewear purchase that is not covered by their allowance plan. If they don’t need prescription eyewear, they should re-evaluate the money they are spending on their monthly vision plan premium compared to what they would pay out of pocket for an eye exam and plano sunglasses and ask themselves: “Is this vision plan really saving me any money?”

Cory S.
Las Vegas, NV

As frustrating as it may seem, most vision plan contracts prohibit this type of activity. The intent is to defraud a vision plan. If there is a plano sunwear option it will be stated in the benefit. You will not only lose your contract, but also face heavy fines, penalties and possibly legal action. Something similar would be for a patient to “give” their frame to a friend or family member. This also constitutes fraud. Better have your ducks in a row to show you were not complicit in the scheme.

Caitlin W.
Montrose, CO

I would not be comfortable with the situation at all. Letting patients know that is insurance fraud would be my first step. Also, most companies will write out the policy, which I would show to the patient and explain why it is not something we are willing to do at our practice.

Missy D.
Spokane Valley, WA

We always let the patient know what their insurance benefits are. If their prescription is valid for lens coverage but the patient just wants plano sunglass lenses, we explain that we will need to fill the lens prescription to utilize their lens benefit and we dispense the eyewear with the prescription lenses mounted in the sunglass. We give the patient the stock plano/demo sunglass lenses and let them know if they don’t like the prescription in the sunglass after giving them a try we can mount the plano/demo lenses back in. We’ve used their benefit according to their plan, explained coverage to the patient but also allowed the patient to keep all parts purchased. The original stock plano/demo lenses were part of the frame the patient is purchasing (even if they are using their insurance coverage), so they should be allowed to keep them. It becomes up to the patient after that, what they do with those lenses.

Pat R.
Irving, TX

According to both VSP and EyeMed this is fraud. We don’t do it where I work. We have patients try and we tell them no. However, as long as the patient is really getting prescription lenses they will actually use, I don’t mind giving the plano lenses to them for future use if they can no longer use the Rx lenses.

Judy M.
Pittsfield, MA

I would give demo lenses with a sunglass frame. I would not order Rx lenses knowing the patient is not going to use them at all. I do agree with the doctor to give the demos to the patient as long as they have ordered Rx lenses that they will use. The reason I give demo lenses is if in the future the customer wants contact lenses or to let someone else have the sunglasses, they have the demos. If the business gets audited, they will have to face the consequences. If I were Ellen and the doctor wanted to continue this practice, I would look for another job.

Judy C.
Virginia Beach, VA

The doctor and optician may consider it a gray area, but the vision care plan will not. Fraud is fraud, no matter how well intentioned. Another big “if” is the patient seeing another, different practice and expecting the same “help.” One complaint to his vision care plan about perceived unfairness will surely trigger an audit and will definitely expose other discrepancies for as many years as are investigated. Regardless of the doctor’s actions, the office manager should document both her findings and her conversations about the issue with the doctor. Whether the office manager stays or leaves is a personal choice, but she must understand that her professional reputation will be at risk if and when an audit is done. In addition, she may be liable for hiding the fraudulent claims.

Jennifer L.
Dansville, NY

You have to abide by the contract you commit to with the insurance company. If they do not allow plano eyewear you must not make a revision so they can get plano eyewear. I also believe that when you sell a plano pair of sunglasses then Rx them, that person bought the demos with it — give them to them. If they decide later to swap out the Rx lenses for the planos then do it. It’s ridiculous to nit-pick some of these things but you have to honor the legal contract you agree to. Explain the situation to the patient, how illegal activity can shut down your business, and how important it is for you to be legit. Tell them you can’t control what they do when they leave the office or in the future, but what happens in your office is always above board and transparent. Your reputation and integrity are top priority.

Leisa L.
Newport Beach California

Where a patient uses their insurance plan for sunglasses and the frame has plano lenses mounted the lenses are part of the frame purchase and should be at least offered to the patient when dispensing the completed glasses. If the patient also wears contact lenses and decides to use the plano lenses that is their choice. If a pair of lenses are cut for the patient that are not actually the patient’s Rx, that is a completely different situation. It should not be considered insurance fraud when making the proper Rx for sunglasses. There are other ways to handle the sunglass sales. Recommend two different pairs, one for wearing over the contact lenses and a second Rx pair without the contacts. In fact, there have been several sunglass frames made with pop-out lens ability just for this purpose. The Porsche Carrera and a Cazal come to mind immediately.

Rigo L.
Indio, CA

Wow, this is a tough one, depending on how you see it or how you work the insurance. Where insurances don’t pay much, in a small private office where we want to make some money off insurances, why not? On the other hand, I have worked in a larger practice with multiple locations where this was out of the question. I don’t see a fraud issue as long as the patient has the minimum Rx, they understand what we are doing and the lenses get dispensed. Where it becomes a very dark gray area is when you are trying to save the patient money and you bill the insurance for a different frame and not dispense the lenses. Even though the patient has an Rx you are basically lying to the insurance company and this can be a big issue. In Ellen’s case she sounds like, and I could be wrong, an old school optician. There is nothing wrong with that as long you are good with, and open to, change.

Stewart G.
San Francisco, CA

1) VSP guidelines state that the demo lenses are not to be given to the patient. So, the answer is no.
2) You can’t protect the business. The business has committed insurance fraud. And VSP guidelines are such now that they can go back years and request you pay them back for all those orders plus interest plus penalties AND you can get kicked off the roster.
3) Ellen may need to put what she said in writing to protect herself, or start looking for a new position in a different office.

Pablo M.
Alpharetta, GA

1. No, we do not hand out the clear demo lenses, so why do the color ones? It is supposed to be an Rx job for insurance purposes, right?
2. How do you protect the business if it gets audited by the vision plan in question? Turn witness for the prosecution, your honor…
3. I would try to explain to the good doctor why this is all a bad idea all around, and if the doctor decides to keep doing it, it will be without my help. I deal too much with insurance as it is to get involved in these kinds of messes.

M. Pastor
Phoenix, AZ

In this scenario, Ellen is completely correct! The doctor/owner is a complete idiot and should not be in business if he is willing to commit insurance fraud! Ellen, find a new job with an ethical practice!!

Donna
Mission, British Columbia

I would never do this; it’s insurance fraud. My credentials and reputation are worth way more. I would never protect or work at a place that allows it.

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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.

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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