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Posts Tagged ‘patients’

Friendly Reminder that Utah Expiration Dates are Two Years

David Langford, O.D. on July 26th, 2012 under Optoblog •  3 Comments

When I went to renew my Utah optometrist license, I was greeted with this pop up:

Utah DOPL two year contact lens expiration reminder

Utah DOPL two year contact lens expiration reminder

Since my photo is grainy, it says,

“Under Utah law a contact lens prescription expiration date shall be two years from the commencement date unless documented medical reasons require otherwise.”

Here is the excerpt from the Utah Code regarding “Contact lens prescription”:

58-16a-102. Definitions.
(b) A prescription may include:
(i) a limit on the quantity of lenses that may be ordered under the prescription if required for medical reasons documented in the patient’s files; and
(ii) the expiration date of the prescription, which shall be two years from the commencement date, unless documented medical reasons require otherwise.

I would say it is pretty standard practice to make youth Rx’s one year, but my advice to other Utah eye doctors would be to make sure you have a check box in your chart documenting how the youth’s Rx is still changing which requires yearly monitoring, history of eye infections and need to yearly monitor eye health, etc.

I am not exactly sure when this law came into effect, but I have known about it since 2006 after I moved to Utah. From intermittent observation of outside Rx’s brought in to my vision center or patients coming in for an exam, I would say about half of the area eye doctors know about this law. Either ignorance or they document every little thing as an excuse to yearly monitor contacts. I don’t want to slight The Vision Council’s campaign of “Check Yearly. See Clearly.” but the law is the law.

What would you say is sufficient medical reason to change an adult’s contact lens Rx to less than two years?

  1. Seasonal allergic conjunctivitis? What would you change before two years after recommending Pataday/Alaway, ClearCare, and daily disposable during the worst weeks?
  2. Contact lens-related dryness? What would you change before two years after recommending Oasys/Biofinty and ClearCare/Optifree PureMoist and Refresh Contacts?
  3. Mild corneal neovascularization? What would you change before two years after recommending a silicone-hydrogel, adhere to manufacturer replacement schedule, and no overnight wear?

I would be careful because if you get too knit-picky, your patients will go elsewhere for exams.

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“Use of Optical Scan Machines” H.B. 408 Utah State Legislature 2012

David Langford, O.D. on February 9th, 2012 under Optoblog •  12 Comments


SpecBox Coming Soon?

The Utah Optometric Association is very worried about H.B. 408 which is being introduced for the 2012 legislative session. I know they must be worried because a volunteer optometrist from the association called me, and I’m not even a member of the UOA.

It turns out they are rightfully worried because while the title, “Use of Optical Scan Machines,” might seem innocuous, what is really behind the curtain is pernicious.

While there is currently no text on the le.utah.gov website for H.B. 408, sources say that the bill’s sponsor, Greg Hughes, from Draper, UT (home of 1800Contacts) intends to allow the current prescription law to be changed to allow a person to buy glasses based on the reading of an autorefractor.

Apparently, the plan is for a company, like 1800Contacts, to set up a Glasses Kiosk in a popular store, like Walmart. (By the way, 1800Contacts has been selling glasses for a while.) The person puts their head in the machine, the autorefractor spits out some glasses numbers, a pupilometer measures a p.d., the person selects their frame and lens options, then they slide their credit card and wait for their glasses to arrive in the mail. (Maybe a nicer kiosk would measure the Rx in your current glasses and have you look at an eye chart, and factor those measurements into the numbers the kiosk “prescribes” you.)

If allowed, I predict an unintended consequence will be that no optical will adjust your glasses for free, like they currently do. You will have to show a receipt just to get your glasses adjusted, so everyone buying glasses from kiosks or internet sites will walk around looking like goobers and in pain from poorly adjusted glasses.

Other obvious consequences will be that people will walk around with headaches and blurry vision since autorefractors are notoriously inaccurate and will usually over-estimate nearsightedness and underestimate farsightedness. And say nothing of the fact that many people need prism to see straight/avoid headaches.

But here is the biggest reason to forsake this bill: People need eye exams to ensure good eye health. A refraction is only one piece of a complete eye exam. I’ve already written about the woman who only wanted more contacts, but because she had an eye exam, I saw some worrisome findings and referred her for more specialty care which discovered a brain tumor.

That’s just one patient. I’ve actually done that a couple times with brain tumors. Other times I’ve had patients whom I’ve diagnosed leukemia, diabetes, pituitary adenoma, increased cerebral spinal fluid pressure, glaucoma, macular degeneration, eye infections, allergy eyes, and more all just from a “routine eye exam.” None of these people thought there was something wrong- they just wanted new glasses or more contacts.

We can’t ignore that an eye exam is more than just looking at an eye chart and getting a refractive prescription.

But let’s say you wanted to. Let’s say you are simply a consumer advocate who wants to help people buy glasses. Your idea is to waste everyone’s time and money by making a law to separate the refraction from an eye exam. The consumer who values their eye health will simply also get an eye exam in addition to buying a glasses Rx and purchasing spectacles from a kiosk.

Okay, Utah Legislature, why are you stopping there? What if I’m a business that wants to sell antibiotics cheaper, to more people, than the present system of physicians and pharmacies? I want to set up kiosks that take your temperature. If you have a high temperature, you get vended an antibiotic. Sounds great for consumers, right? Why should eye care providers and opticals be the only ones to suffer? Make physicians and pharmacies suffer as well!

If you want to change the system, change it fairly for everyone. Let’s be just like third world countries which don’t require doctor prescriptions at pharmacies or optical shops. If it’s about consumer advocacy, what could be better, right?

Of course, you will essentially be forcing a large portion of health care providers to change professions. And don’t even mention how news reports will be full of people self treating, taking the wrong medicine for the wrong diagnosis, and dying. It’s a small price to pay for consumer choice, but since I have some libertarian leanings, I wouldn’t mind trying it out as long as every medical profession participates and not just optometrists.

However, if you don’t think that all roads should be toll roads and marijuana should be legal, then let’s continue to require prescriptions for medicines and medical devices, like glasses and contacts.

Choose one, Utah Legislature. Just be consistent across all professions to make the playing field level.

If you have an opinion on 2012’s H.B. 408, then contact your Utah lawmaker.

On a side note, I hope the sponsor of H.B. 408, Greg Hughes, is happy with himself. The UOA is burning tens of thousands of dollars (that it can’t afford) on lobbyists that only work for six weeks to fight H.B. 408. Even if HB408 is defeated this year, who knows if it will come up again next year and they’ll have to spend more money again! Mr Hughes, I’m not sure how you can sleep at night. You are causing poor optometrists to spend tons of money fighting legislation that you introduced only because a big business told you to. Even if you said you were sorry and withdraw the bill, you can’t un-burn the cash you’ve caused to be burned.
Please, lawmakers, try to think outside your wallet when making decisions about bills to consider during legislative sessions. I propose we only allow you to meet every two years in order to provide more stability for us business owners.

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How to Drastically Eliminate Insurance Fraud

David Langford, O.D. on June 9th, 2011 under Optoblog •  Comments Off on How to Drastically Eliminate Insurance Fraud

This week I heard about a New York physician telling all his medicaid patients that they had HIV/AIDS, even though they didn’t, because he could bilk Medicaid for tons of money running HIV testing/office visits.

Today I hear about an optometrist in Utah who bilked Medicaid for patients he never even saw!

Before insurance companies (especially government ones) start bearing down on all of us with burdensome regulations because of a few bad actors, let’s take a step back an look at the problem from a different angle.

This is why insurances shouldn’t pay for physician office visits, but if they want to, then leave the doctor out of it and just reimburse the patient. My car insurance doesn’t pay for oil changes or gasoline. If my car insurance was crazy enough to offer an oil change benefit, then that would be great, but if I’m Convenience Lube, then no way would I take deferred payment from some car insurance company. I would demand the car owner pay at the time of service, and their crazy insurance company can reimburse the car owner later. If my car is in a major accident, then I would less likely have cash on hand for an expensive repair, so this is when the insurance companies would step in. Besides, autobody shops are much more accustomed to dealing with insurance compared to oil change shops or gas stations.

This is how it should be in healthcare. Only certain providers would really have a need to regularly bill insurances. Mostly doctors doing surgeries, hospitals, or other high cost care environments.

Number one, this helps lower the cost of medical care because people find out how much it actually costs since doctors don’t have a big menu/price sign over the reception desk. Second, doctors don’t have to spend tons of money and time filing claims. Third, the incidence of doctors perpetrating insurance fraud would go down because doctors would have less opportunity anyway. Fourth, if something isn’t covered by insurance, who presently gets to eat it? Usually the doctor. Patients paying their own office visits would force the patient to be more accountable for whether they really want/need a particular service, regardless if they expect their insurance to reimburse or not.

The doctor shouldn’t be beholden to any insurance company. He should deliver care according to his training/experience. She shouldn’t have to try to remember that Insurance A will pay for a visual field once a year, but Insurance B will allow it twice a year, etc. He shouldn’t think about if he has the patient do an extended medical history, he can upgrade his exam from level 3 to level 4 to bilk the insurance company for all they’re worth because hey, the patient is only paying a copay, right?

I think big ticket items like billing for surgeries or expensive procedures should still be billed by providers/hospitals since this is what insurance is for: paying for catastrophic, unexpected events. But all the little stuff, like inpatient food service and routine exams and regular office visits should be paid up front by patients. It would lower healthcare costs because providers could lower prices since their labor and accounts receivable would decrease. It would decrease over-utilization since patients have a financial stake in the process. It would decrease fraud since there would be less opportunity to create fraud by the majority of doctors/patient encounters.

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Optoblog Poetry #005

David Langford, O.D. on May 18th, 2011 under Optoblog, Poetry •  Comments Off on Optoblog Poetry #005

I shine light in eyes,
as a watchman for disease.
Patient might punch me.

I get photophobic patients sometimes, so this haiku is for them. If you liked this one, read more Optoblog poetry.

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UT Medicaid Doesn’t Allow Optometrists to Bill Cornea Topography

David Langford, O.D. on May 18th, 2011 under Optoblog •  1 Comment

Utah Dept. of Health logoI tried billing corneal topography (92025) to Utah Medicaid as part of managing a patient’s keratoconus, and I was shocked to have it denied. The reason?

The procedure code is inconsistent with the provider type/specialty (taxonomy).

So I called Utah Medicaid, and confirmed that 92025 is the code for corneal topography, and they confirmed that optometrists are not allowed to be paid for corneal topography because only physicians and hospitals are allowed to bill this procedure code. I pressed that optometrists manage conditions like keratoconus with corneal topography and that their policy definitely needs to be changed. The UT medicaid worker said she would bring it up at their meeting, but that meeting isn’t until next week, and she had several other issues that weren’t address at the last meeting.

So, I think she was telling me that she couldn’t guarantee that anything regarding my issue would be addressed in the near future. Even if they do discuss it sometime this month, they might not change their mind.

THIS IS COMPLETELY RIDICULOUS!!!. Hospitals? Hospitals can bill for corneal topography? How often do they do that? Can we name even one hospital that even owns a corneal topographer? The only physicians who use corneal topographers are ophthalmologists, but if I were a pediatrician they would allow me to bill for it?

Attention Utah Medicaid Taxonomy-Procedure-Provider-Type Committee: I hereby declare that you should immediately allow optometrists, provider type 31, to bill and be reimbursed for computerized cornea topography, CPT code 92025. Blue Cross allows it. I am trained to perform and analyze this test in optometry school. I need it to manage conditions like keratoconus, irregular astigmatism, pterygium, pellucid marginal degeneration, and transplanted cornea. All of these conditions I see in my practice.

Until now, I am willing to grant that the taxonomy/provider-type thing is an oversight- a snafu with the computer database. Now that this error has come to light, the only reason I can think that Utah Medicaid would continue in this erroneous policy is that the committee members making that decision are a bunch of anti-optometrist bigots. I don’t want to think that, so please reverse your policy as quickly as possible and allow optometrists to bill corneal topography.

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What Should be the Line between Optometry and Ophthalmology?

David Langford, O.D. on May 10th, 2011 under Optoblog •  Comments Off on What Should be the Line between Optometry and Ophthalmology?

Kentucky now joins Oklahoma as the only states that explicitly allow optometrists to perform laser surgery on/around the eyes and even lumps and bumps removal.  (Read the article here.  H/T to kevinmd.  Also see a news article here.)

When people ask me what’s the difference between an ophthalmologist and an optometrist, I always like to say, “Optometrists do everything an ophthalmologist does except surgeries.”  (By the way, I don’t consider foreign body removal a surgery. Chalazion removal- yes, definitely a surgery.)  Even one of the ophthalmologists in the feature story seems to agree with that statement:

“We draw the philosophical line in the sand with surgery,” says Dr. David Parke, chief executive officer of the American Academy of Ophthalmology.

Of course, proponents of the bill think that allowing ODs to perform laser surgeries is good for people because, as Governor Beshear explains:

“I signed Senate Bill 110 to give Kentuckians greater access to necessary eye care.”

Now, I would probably refute that it gives people, particularly rural people, greater access to eye care. For a doctor to buy all the necessary equipment to perform a YAG capsulotomy, he would need to invest in a pretty expensive piece of equipment. To keep up payments, he would have to do a lot of procedures. How many YAGs does a rural optometrist usually see a month? Probably not a lot. How far away is the surgeon who did the patient’s cataract surgery in the first place? Probably not that far.

subtenon injection

subtenon injection

subtenon injection materials

subtenon injection materials

Optometrists are already trained in school to do periocular injections, but can an optometrist be trained to do YAGs? Absolutely. It’s an easily learned skill that is widely studied for potential complications and side effects. This stuff is not magic- it just needs training. But it’s also a skill that, if not done regularly, can get lost. If I had a patient tomorrow that needed a subtenon’s injection, I would have to refer them out because I haven’t had to do one since leaving optometry school. No way would I feel comfortable. I also think that it’s in the patient’s best interest to have a procedure done by someone who does that particular procedure regularly.

Anyway, I kind of like my definition of optometrist. What do you all think?

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CibaVision is Discontinuing O2Optix

David Langford, O.D. on February 22nd, 2011 under Optoblog •  Comments Off on CibaVision is Discontinuing O2Optix

I just got word that Ciba will discontinue O2Optix soft contact lenses. The time line appears to be:

  • 7-1-2011 Doctors will no longer get trials for O2Optix
  • 1-1-2011 Product availability not guaranteed
  • 7-1-2012 O2Optix lens discontinued.

Ciba has been pushing strongly the one month replacement modality which flies in the face of the two week replacement schedule philosophy of their competitor, Vistakon. Ciba’s recommended alternative for those who have been in O2Optix lenses is to have their doctor refit them in Air Optix Aqua.

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Walmart not selling Clear Care now

David Langford, O.D. on January 25th, 2011 under Optoblog •  4 Comments

UPDATE 2-26-2011: Ciba and Walmart came to an agreement, and ClearCare will soon be available at your nearest Walmart very soon if it’s not there already.

Walmart will sell out their existing stock of ClearCare, but won’t be reordering more. Here’s from the memo dated 1-24-2011:

  • Jan 1, 2001 Ciba Vision has incorporated a substantial cost increase to their Clear Care items throughout the industry.
  • We take any and all cost increases very seriously especially if the supplier is unable to justify the significant increase completely.
  • In the interest of our customers, we will not carry Clear Care until this matter is resolved.

They go on to suggest that the V.C. associates can ask the Doctor Partners to recommend a suitable alternative product.

Isn’t this what happened to Rubbermaid?

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Colorblind? There’s an App for That.

David Langford, O.D. on December 15th, 2010 under Optoblog •  2 Comments

Dan Kaminsky's DanKam

Dan Kaminsky's DanKam

Dan Kaminsky created an iPhone & Android App for people with red-green color deficiencies. It exaggerates the hues after you take a picture on your app-phone.

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Sheldon’s Grandpa goes to the Eye Doctor

David Langford, O.D. on June 21st, 2010 under Optoblog •  Comments Off on Sheldon’s Grandpa goes to the Eye Doctor

See it and read it here.

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