By Eric Botts, OD
One of the most difficult conversations to have with your patient is explaining why today’s examination is medical and not routine. In many cases using their routine benefit is less out-of-pocket expense to the patient and in today’s economy the patient wants to save every dollar they can. However, if the exam is determined to be medical by you the doctor then it is necessary to explain to the patient that the exam will be submitted to their medical insurance carrier. Fortunately this scenario will become easier once all of us accept the responsibility to step up and be the medical optometrist we were trained to be. Anyone believing that the future of optometry will only be refractive in nature needs a healthy dose of reality. Medical optometry is here and will be a major part of optometry now and into the future. So let me offer some suggestions on how to start the conversation with your patient.
- The conversation can begin as early as when the patient calls to schedule the appointment. Ask the patient if they are diabetic and if their response is yes then explain that the exam will be medical due to their current history of diabetes which is a leading cause of blindness here is the US. Many health insurance plans today require notation in the patient record of the primary care doctor treating diabetes that a yearly dilated fundus exam was performed. This is also the time to ask for patient’s insurance information so eligibility may be determined prior to the appointment.
- When the patient enters your office, be sure to make copies of all insurance cards used by the patient. This is an excellent opportunity to plant the seed that you can do more than just prescribe glasses and contacts but also diagnose and treat many ocular diseases. Confirming eligibility benefits for both routine and medical benefits prior to appointment is necessary for efficient patient flow.
- Confirming eligibility for health insurance plans may be quickly performed using many of the clearinghouses currently utilized for electronic claim submission. If that is not an option many of the health insurance carriers also have websites available that allow you to check patient eligibility. Navinet, Availity and several of the Medicare carriers have free web portal access to patient eligibility information. Checkmedicare.com is a pay per claim service that offers eligibility information as well.
- It is appropriate to discuss with the patient fees associated with medical visits and procedures performed to diagnose ocular disease. Educating your patient on the services you provide is the responsibility of you and your staff and is a critical step in building a successful optometric practice. Explain to your patient why a retinal photo is necessary to document the presence of diabetic retinopathy or a threshold visual field and OCT scan are required to follow the progression of glaucoma and the patient will return to your office for required follow up care. Patients with ocular disease may become your most loyal patients resulting in patient referrals that build a successful practice.
Part of the confusion patients have about medical and routine optometric eye care is derived from the on-going confusion many doctors and staff have on the same topic. Doctors and staff need to be confident in their communications with patients on the care they are providing their patients. Medical and routine eye exams are as much the same as they are different so doctors and staff misunderstandings spill over to the patient. Here is a brief explanation:
- Chief Complaint or Reason for Visit
- Refractive in Nature
- Elements of Exam
- Low or no Medical decision-making
- Primary diagnosis is refractive
- Chief Complaint (CC) or Reason for Visit
- Medical Necessity
- Elements of Exam
- Medical decision-making
- Medical Diagnosis correlates with CC
The primary difference is the chief complaint (CC), decision-making and diagnosis. If the CC or primary diagnosis is refractive in nature then the exam is most likely routine. If the CC involves medical necessity and correlates with a primary medical diagnosis then the exam is medical. Often the history and elements of the exam may be similar or even identical so focus on the CC and diagnosis to differentiate routine from medical.
Another option to help your patient understand the difference is to use an intake form that explains when routine or medical insurance will be used and also that the decision is made by the doctor depending on the presentation and diagnosis of the patient. This form is presented to the patient prior to beginning the exam so they can read it and sign it to acknowledge their understanding of routine and health insurance benefits.
Remember these conversations are necessary today because more and more patients are acquiring health and routine insurance. Fortunately as more and more of our colleagues provide full scope medical optometric care instead of giving away their medical services during a routine eye exam the conversation will become less frequent because if we all share the same message with our patients they will quickly understand when their routine and medical eye benefits will be utilized.
Photo: Copyright: nyul / 123RF Stock Photo
Eric Botts, OD is in practice at the InnovativEyes clinic located in Walmart Vision Centers in Macomb, IL, Galesburg, IL and West Burlington, IA. He is also President of OBC Billing Specialists located in Macomb, IL. This service helps credential doctors and submit routine and medical claims for optometric practices that choose to out-source their billing needs. He also lectures extensively on medical billing in an optometric practice. He may be reached at 309-333-6344 or firstname.lastname@example.org.