optoblog.com

So I have OfficeMate in my practice. I started using them in 2006 with release 7.x, and I currently have 8.x. It uses an access database which never really needed a server because it’s just a file that you could put on one computer and share it peer to peer. At the time I went ahead and bought an expensive Windows/Dell server because they recommended it, but I found out later from working with it that I could have just put the OM db file on cheaper network attached storage.

Anyway, along comes progress. OM with release 9 has implemented the famous, awesome SQL database. What makes it famous and awesome is that SQL is opened source and cross platform. So of course OM implements a Microsoft only version of SQL. The Windows Server Small Business that I’ve been using isn’t supported, so now I am faced with paying a whole bunch of money for a new edition of Windows Server standard. If I upgrade to that, I might as well update my client machines to Windows7. If I do that, my current video cards don’t support it, so I’ll have to either buy new video cards or just a new box.

So now, with all that plus the yearly, over $1K fee for OM, I’m wondering if I shouldn’t start over with some other solution. To tell you the truth, the only thing I use OM for is electronic billing. I just scan my paper charts with my awesome and fast Fujitsu Fi-6130 document scanner.

I really wish OfficeMate would have implemented a cross platform implementation of an SQL db. I could have just used a free Linux server to host the db.

For you optometry students trying to make up numbers for your business plan, here are some percentages from my average Walmart practice:

In 2007 and 2008 I didn’t track the percentage of patients using insurance because I didn’t have to bill very much back then.

For more interesting stats to help you make your business plan, the OBA-CE has compiled these:

• Revenue Per Exam
• Complete Exams per OD Hour
• Annual Revenue Growth Rate
• Internet Site Penetration
• Contact Lens Usage by Lens Type
• Recall System Independent of Vision Center
• Walk-in Ratio
• Contact Lens Exams Percent of Total Exams
• Medical Eye Care Visits as Percent of Total Visits
• Exams Percent of Active Patients
• Professional Fee Income Percent of Total Location Revenue
• Performance Metrics by Years at Location
• "Elite” Practice Metrics
• Performance Metrics for Walmart and Sam’s Club Locations

I got a letter this week from PEHP, a division of Utah Retirement Systems. PEHP stands for Public Employees Health Program. They state that:

Beginning April 15, 2010, PEHP will no longer reimburse consultation codes. Providers will need to bill the appropriate Evaluation and Management code for the visit.

I’ve probably never had to bill a consultation code, but I imagine ophthalmologists won’t be too happy with this change.

I wonder how long it will be until every insurance company finds out that private pay individuals rarely get billed the higher fee consultation codes…

I think we should all consider going the route of “insurance free medicine.”
From guest blogger Dr. Mintz at Kevin, MD:

Thus, I think a term that I would like to propose for use in further discussions of newer ways of practicing primary care is “insurance free medicine.” The term “insurance free medicine” captures the essence of the newer models of primary care. Patients have certainly seen their premiums and deductibles increase and can probably relate quite well to reasons why a doctor would not accept insurance.

Insurance free primary care practices could certainly adopt retainer membership fees and promote improved access, but eliminating terms like “boutique,” “concierge,” and “cash only” might help eliminate the notion that primary medical care without insurance is somehow tainted or only for the super-wealthy. Previously, I discussed that without substantial changes, primary care will soon go the way of psychiatry in that patients who use their insurance to see a psychiatrist get one kind of care (very brief visits, mostly management by a non-physician) and those who pay their psychiatrist out-of-pocket get the kind of care that we see in TV and the movies.

With more frequent use of the term “insurance free medicine,” patients might start realizing that if they continue to pay their primary physician using their health care insurance, they should expect even briefer visits, longer waits to get in, seeing non-physicians, and greater delays getting a return phone call or results back.

I calculated the other day that I spent about $2000 a year to be set up and able to bill insurance. Further, I spent all that time and money for about 538 patients, or close to one-fourth of my patients per year. Now that Walmart no longer bills many vision plans for me, both numbers will go up, and so will my accounts receivable. In anticipation of this, my fee went up by $5 per patient at the beginning of the year.

I would lower my price if we could all convince the general public that routine medical office visits should be paid out of pocket. Your car insurance doesn’t pay for oil changes.

The not so simple question...

There is a not-so-simple question that pretty much every patient asks, “How much is your eye exam.”

While the medical model has varying levels of exam, like Level II-New vs. Level IV-Est, which depend upon the history, exam, and complexity of that particular case; however, there are some among our profession that make it an especially hard question to answer, and this issue raises concern over the ethics of a fairly popular fee structure.

For example: the price in front of the Big Box says “Eye exams starting at $45!”
But are they really? Sure, for a “routine eye exam” where nothing is wrong and you just want your glasses updated, then it’s the $45. But what if I have some allergy eyes, so the doctor gives me a prescription for Pataday as well as my glasses Rx? All the sudden the exam somehow costs $120!?!?

Huh, something funny going on around here. I think big box doctors are more likely to do this since their exam fees are so low, they make up for it by gouging in other fees. I have no problem with a doctor who says their S0620 is $100 and their 92004 is $120. However, I think there is something wrong if the S0620 is $45 and the 92004 is $140.

It’s like some among us in the optometric profession are playing the windshield chip repairman scheme.

But what really happens? Patients won’t typically notice this bait-and-switch. It’s really the insurance companies who get hammered. The patient pays their copay, and if the doctor can come up with any excuse to bill a medical code, they use their medical model fee structure to justify it.

Ethics applies when we realize that, for some reason, private pay patients are rarely charged the same high fees as the insurance companies. Huh. Oh well. It’s a victimless crime because those big, bad insurance companies won’t miss the extra cash. Until we realize that the more insurance companies pay out, the more the patient’s premiums will be raised next year. Whoops. Sorry, Mrs. Smith, that you can’t afford to keep your medical insurance in the future because I wanted to get paid double or triple my usual fee because you have insurance today.

By the way, it cost me about $2000 to bill insurance last year (PIM software license, E-filing charges, and postage/paper for mailing statements/refunds). Also add to that the cost of time spent filing claims and handling overpayment and underpayment. If I didn’t have to deal with insurance, I could drop my exam fee by at least $5 per person.

I have an idea: All patients should pay for office visits out of pocket. If they have insurance, get reimbursed later. The doctor won’t know about their insurance, so there won’t be a conflict of interest about what exam fee structure he’ll choose. The doctor can lower his fees since filing claims is expensive and time consuming. Everyone wins. Another idea, insurances should allow me to charge either them or the patient a $5 claim filing service fee.

Take home point: I don’t believe it is ethical to have one fee structure for insurance patients and another drastically different one for private pay. Yes, I’m all for charging more money if something is more work and more time. That’s why a contact lens evaluation is paid on top of the routine eye exam. That’s why there are different levels of 99*** office visits. But sneaking a huge fee onto an insurance claim just because there is some medical code excuse is something I don’t think our profession should feel comfortable with.

With Walmart’s announcement of a sweeping change about getting out of the business of billing vision insurance companies for their doctors, a whole new cottage industry has sprung up. Businesses are soliciting Walmart doctors to let them handle all the insurance billing.

Yup, I’ve said it before and I’ll say it again. Ophthalmic vendors think we optometrists are so stupid. Just because we picked this profession, they think we are prone to making poor financial choices just like some people are accident prone.

Any of you vendors seeking to do insurance billing for me are wasting your time. All I need is my practice management software and Apex EDI. It’s as automated as can be. Most of the vision insurances have their own website for authorization and billing, and then I use Apex EDI for my BlueCross, Medicaid, DMBA, and other miscellaneous insurance companies. (You can do Medicare also, but I am disinclined to participate with them.)

Apex EDI works great. It’s fast and easy. And I don’t need no stinking slick Rick to be some unnecessary middle man. It’s cheap too. I pay 43 cents per claim, less than a postage stamp these days. I also pay the extra $20 a month for the ERAs and Electronic Tools which make my life a lot easier, so it’s worth it.

Call up Apex EDI and tell them I sent you. Use my Champions Code (sales code) to get a better deal: Champ148. I use it in my practice (VisionHealth EyeCare PLLC), and you can use it in yours without the growing cottage cheese industry of Walmart insurance billing middle men.

[Note to Slick Ricks: Any more “comments” made by you to advertise your middle man services will be marked as Spam and deleted. Do us all a favor and go con some other profession.]

I had misplaced a BlueCross insurance payment check at the bottom of a pile of papers. By the time I found it, I had missed the 90 day deadline to cash it.

The other day I got a letter in the mail. They were wondering if I needed it reissued. What was very interesting to me is that if I didn’t respond, the law required BlueCross to pay the money to the state of Utah!

So, I wonder if patients should be forced to do the same thing? Or what about doctors who owe patients an overpayment refund? Should we be forced to pay the government if they never cash the check? I guess it won’t matter soon anyway because the way things are heading we’ll all be working for the government. Thanks for reading, comrade.

There was an interesting article written at the AmateurEconomist.com about “Why Doctors Are Not Good Businessmen.”

Hat tip to Kevin, M.D. who commented on this story and said,

“This is why the private practice model of medicine is dying. More practices are being bought by hospitals where the physicians are salaried. This relieves the burden of administrative tasks and supervising ancillary staff, so that the doctor can focus on medicine.”

Rob at VSP says that “[private practice doctors] provide the best care.” Well, if I’ve got the weight of a business on my shoulders, doesn’t that detract from patient care? Additionally, in our field where the private practice doctors sell what they prescribe, can you totally rule out any conflicts of interest which potentially detract from patient care?

Again, independent doctors of optometry in a Wal-Mart setting don’t have the conflict of interest and their administrative duties are much less than private practice.

What’s funny to me is that every CE event I’ve been to always has some talk about why optometrists should start the “medical model” in their practice and watch the money role in. Well, how is adding more third party payers going to help you make more money? Primary care medicine is dying according to Kevin M.D., and yet the roboconsultants are telling us to join more insurance panels. I think getting rid of insurance companies in your practice is the way of the future.

The roboconsultant woos you buy saying that for one case of dry eye you can milk an insurance company for $500-$800 in office visits and procedures. Well, do you do that for every dry eye patient, even the poor self pay patient or the patient with insurance but poor benefits? I would think that doing it just for those with good insurance would be unethical as well as probably insurance fraud.

I think the more your appointment book is filled up, the more you should be able to charge for your services. It’s the old supply and demand of free economics. I think a better system would be for patients to have to front the money to pay the doctor for office visits at the time of service. The patient would have to get reimbursed what they can from their insurance company. Maybe then insurance companies would be forced to have a faster turn around time on processing claims for their patients and be watched more closely for just rubber stamping a denial based on some frivolous billing exercise (or at the least the patient has to worry about it instead of me.) I simply provide the best care for the patient, recommending only the products and services that they need, since now I don’t have to worry about getting paid.

So Rob’s Blog has this to say to people about getting yearly diabetic eye exams. As if optometrists in a commercial setting don’t do the same thing, he tells a big lie here:

…these [private practice] doctors consistently have the longest relationships with their patients and provide the best care.

Rob, people aren’t buying what you’re selling anymore. I see VSP beneficiaries out of network all the time in my Wal-Mart setting. I guess they aren’t loyal to a practice setting, but rather they factor in price and convenience while assuming, correctly, that any doctor they see in my area is competent.

Oh, and I remember when Intel in the Hillsboro/Beaverton, Oregon area was buying your VSP, and then they switched to EyeMed. Does that mean they thought your private practice network of doctors couldn’t “provide the best care?”

But I see what he’s trying to do. Any roboconsultant will tell you that you need to differentiate yourself from the competition; however, I take exception when he lies.