Any doctors or lawyers in the house?

[Terpsichore]

In a nutshell:  The optometrist that I work for tends to run a few extra tests during a basic exam.  Some are necessary, others...debatable.  The office manager and myself are left to deal with the angry phone calls from patients who get a bill for these tests because they think that these tests are part of the exam and they really aren't.  We even have had a patient tell us we run an unethical practice by not informing people that these tests aren't part of the basic exam, but we have no idea what doctor all does until way after the fact when we finally get the coded chart to bill out.

So the big question is...Are we legally required to inform patients of these tests before hand, or is it doctor's responsibility to inform them prior to running them?  We have thought about a form and have pleaded with doctor to tell patients before hand, but both ideas went over like a ton of bricks with him.  Over two thirds of our patient base have mentioned to us that they never would have agreed to anything outside the basic exam if they had been told there may be an additional charge.

Any input would be appreciated.

[Strings]

Paging Millcreek. Millcreek to the white courtesy phone

[T.O.M.]

I'm not that kind of lawyer, but my docs all warn me about anyhing that might not get covered before it gets done.  Good practice to avoid these situations.

[Brad Johnson]

I would think an industry as heavily regulated as health care, even optometry, would require consent before billable services are performed. As I am neither physician nor attorney this is only a personal observation.

Brad

[MillCreek]

While it is the patient's responsibility to know their insurance benefits and what may and may not be covered, the reality is that they do not because they are not insurance experts, and they rely on the office staff to give them a heads up.

This is especially the case with elderly patients with Medicare.  People without vision coverage but with medical coverage often think their refraction, etc., is covered by the insurance company and are shocked and angry when they find out how little the medical coverage applies to routine vision care.

From a patient relations, minimizing possible complaints against the providers' license, or complaints to the patient's insurance company or CMS perspective, I always recommend giving patients notice prior to the exam as to what may or may not be covered and the estimated costs thereto.  I would do this in writing and have the patient sign a financial waiver form accepting financial responsibility for non-covered services.

A good example is Optomap and similar testing.  It would not be difficult to prepare a handout listing the commonly-performed tests that are part of eye care and their costs and give it to the patients so they can make a decision.  If they want the tests, have them sign the financial waiver/acceptance of responsibility form and stick it into the chart.

This is the typical approach used by most providers and I am somewhat surprised that your provider does not do this.  

[Terpsichore]

Our welcome form has print saying that the patient agrees to pay what insurance doesn't, but I highly doubt anyone reads that.  And you are right, most have no idea what their insurance even is, much less what it covers.  It reminds me of the joke floating around optical boards of "What do you mean you can't tell me what MY specific coverage is?"  The office manager and I have been taking it upon ourselves at patient check in to inform patients that if doctor runs any tests, there will be a charge and it goes to major medical, and there may be a bill at the end, but that only goes so far.  The flip side of the coin is people hate doing one more piece of paperwork, but I think this may be necessary.  Much like the HIPPA NPP they sign, we can keep it on record for the year and call it a day.  No muss, no fuss.

[zxcvbob]

When they complain, tell them if they think the charges are unethical, take it up with the state licensing board.  And then give them the phone number.  (and a name would be nice) 

If I came in for a basic eye exam at a fixed price and the doc ran a bunch of expensive extra tests w/o my consent, I wouldn't pay for them.  When you turn the account over to a collections agency, I contact the Attorney General's office.

[Hawkmoon]

The doctor is being unethical.

[lupinus]

I would say if they are coming in for a routine exam and the doctor is taking it upon himself to go beyond that, with no other reason than S&Gs, it's unethical.

Sure there is the standard agreement to pay for what insurance does not, but there is likewise the expectation that the doctor isn't doing a bunch of stuff that doesn't fall under the requested service.


Sent from my iPhone. Freaking autocorrect.

[Boomhauer]

That sounds like lawsuit bait to me. I'd sure as *expletive deleted*ing hell sue if I was billed for tests beyond the basic exam I agreed to without being informed of other tests.

[Andiron]

That sounds like lawsuit bait to me. I'd sure as *expletive deleted*ing hell sue if I was billed for tests beyond the basic exam I agreed to without being informed of other tests.

This.

The rat bastard is padding his bills.

If he thinks additional tests are necessary,  disclosure should be a thing.  I can't think of any reasonable person that would have a problem with diagnostics that affect their vision.

[Northwoods]

You schedule a basic exam, and if the patient doesn't request something beyond that, a basic exam is all that should be provided and all that should be billed.  The only exception to that is if the doc has a reasonable belief that additional tests are necessary, and then (s)he should only proceed with them after explaining such to the patient and gaining consent for the additional expense.  Most people don't know what is and isn't included in a basic exam, especially as those standards change based on common practices evolving over time.

[Kingcreek]

The reality is insurance coverage has gotten much more complicated. people don't want to understand it- they just want somebody else to pay for it.
You can try to inform them and getting a signature on a form might help when the inevitable backlash happens, but the patients usually have the entitlement attitude and nothing changes that.
I had a patient that was informed of noncoverage, signed an advance notice of non coverage form and then filed a complaint with the state attorney general over a $45 bill. My malpractice/liability insurance carrier assigned an attorney to my case and 6 months later they dismissed it in my favor.

[Hawkmoon]

You can try to inform them and getting a signature on a form might help when the inevitable backlash happens, but the patients usually have the entitlement attitude and nothing changes that.

It's one thing if the doctor (or his staff) clearly informs the patient that a test or a procedure isn't a standard part of what they came in for and won't be covered by insurance. It's another story if the doctor doesn't inform the patient, but just goes ahead with the test or procedure.

A number of years ago, the chiropractor I had seen for years was killed in a car accident. I started going to a different chiropractor, who was recommended to me by a friend. My old guy always did the same treatment, no matter what ache I went in for, and it always worked. The new one was always attending seminars to "stay on top of the state of the art." My problem was always lower back -- I was injured in a car accident when I was 14 and the lower back took the hit. One day this new chiropractor blithely informed me that he had been to a workshop on TMJ (tempro mandibular joint -- "jaw") problems. Lo and behold, even though I was there for lower back pain, he suddenly began "adjusting" my jaw. The jaw "adjustment" took all of about 15 seconds, and he added $15 to the bill for the TMJ procedure. Clearly, he was just paying for the seminar by tacking on a useless procedure for all his patients.

I stopped seeing that chiropractor.

I also once walked out of a surgical out-patient clinic because a doctor played fast and loose with disclosure and informed consent. I was scheduled for an elective procedure that was described to me as to be done under a "local." When I arrived at the clinic, the first person who came in to see me was an anesthesiologist. I asked why I needed an anesthesiologist for a procedure that was to be done under a local. He said, "Well, it's really a local with sedation. We knock you out, but it's not like full anesthesia." Then the surgeon came in and told me the same thing. I balked, partially because I just didn't want to be fully knocked out, and partially because I had driven myself to the clinic and if I was knocked out I wouldn't be allowed to drive myself home.

The doctor copped an attitude and gave me an ultimatum: find someone to drive me home, or don't do the procedure. That made things very simple: I got dressed and walked out. I later found a different doctor who really did the procedure under a local, who couldn't understand why anyone wouldn't do it that way. I drove myself to the appointment, and I drove myself home.

Doctors who fail to inform patients about matters pertaining to the patient's care are not acting ethically. The problem is that too many doctors think they are gods and that they're too important to waste their valuable time explaining to a patient what's about to happen.

[KD5NRH]

I'm not that kind of lawyer,

Pass...too easy...just like you.   

One day this new chiropractor blithely informed me that he had been to a workshop on TMJ (tempro mandibular joint -- "jaw") problems. Lo and behold, even though I was there for lower back pain, he suddenly began "adjusting" my jaw. The jaw "adjustment" took all of about 15 seconds, and he added $15 to the bill for the TMJ procedure. Clearly, he was just paying for the seminar by tacking on a useless procedure for all his patients.

Guess that's why I like my usual chiropractor; adjustment is $35, (up from $20 over the course of a decade or two) and covers 15 minutes on the roller table and then pretty much anything that doesn't require special equipment.  I've gotten a dropped cuboid, sore elbow, popping jaw, popping knee, quite possibly seriously dislocated shoulder, and a stiff hip fixed in addition to the usual back-and-neck adjustment for no additional charge.  Also doesn't hurt that he sticks to actual joint-related stuff (and reasonable secondary effects, like headaches from a screwed up neck) and doesn't try to convince folks that everything from allergies to cancer is caused by a misaligned bone somewhere.  This is also the same chiropractor who, when a GP said I just needed some muscle relaxers for a back injury, did x-rays for $150 and gave me the film with the slipped disc circled and big arrows pointing at it, then measurements showing my pelvis was cocked to one side as a result, causing soreness in one hip and knee.

[RevDisk]

It's unethical but common practice to bait and switch. The smarter offices will say what is or is not routinely covered.

Went through this with an optional alternative to dilation at the eye doc in box at Lenscrafters. They had an expensive machine that did the same thing, but charged an extra $XX for it. Hell yeah I'd be willing to pay that much instead of wait a couple hours to see like a normal person again. They were upfront that it was optional and extra.

[Terpsichore]

You schedule a basic exam, and if the patient doesn't request something beyond that, a basic exam is all that should be provided and all that should be billed.  The only exception to that is if the doc has a reasonable belief that additional tests are necessary, and then (s)he should only proceed with them after explaining such to the patient and gaining consent for the additional expense. 


I agree.  The next question is, then; "What is considered reasonable belief?"  Is it only if there are clear signs that a patient might be a glaucoma suspect?  Or is a family history of eye issues so it is good to check just to make sure?  This feels like the office manager and I are stuffed in the middle of this, because we can only try to inform patients so much and give them as much information as we can, and then to be called unethical?  Frustrating.

[Hawkmoon]

^^^

Are we talking about checking for glaucoma? Are you telling me that checking for glaucoma ISN'T part of a basic eye exam? And that checking for glaucoma isn't covered by health insurance?

If that's what you're saying, I'm in shock. Every eye exam I've had since I was about fifteen years old has included a check for glaucoma, and it wasn't extra. How long does it take, ten seconds?

[Terpsichore]

Doctor checks for glaucoma.  That, to my knowledge, is standard practice across the board.  He will run visual field tests and then refer patients to other doctors, only for the follow up report to come back clean with the other doctor not seeing any sign of what my boss saw.  Or at least, not to the degree that would justify visual fields every three to six months.  You would think that if there were a legitimate reason for extra anything in a medical field, a patient would at least consider the option?  Is there such a thing as "too careful", when it comes to health?  There has to be a middle ground somewhere between the patient getting quality care and not getting stuck with unexpected bills...

[Boomhauer]

There has to be a middle ground somewhere between the patient getting quality care and not getting stuck with unexpected bills...

The answer is telling the patient "Here's what's included in the exam and here's what's extra that we recommend, what would you like to do?" If they don't want to spend the money or whatever that's on them...making the decision for them is not right IMHO.

[Hawkmoon]

Or at least, not to the degree that would justify visual fields every three to six months.

Every three or six months?!?!? Is this one patient, a few patients, or most/all of the patients? If it's more than a VERY few, that's just flat out ridiculous.

You would think that if there were a legitimate reason for extra anything in a medical field, a patient would at least consider the option?  Is there such a thing as "too careful", when it comes to health?  There has to be a middle ground somewhere between the patient getting quality care and not getting stuck with unexpected bills...

In order for a patient to consider an option, the patient must first know that it is an option rather than part of the standard, basic exam. Then the doctor has to explain the reasons why the options might be worth pursuing, the potential benefits deriving from exercising the option, and the potential downside to rejecting the option. There's a name for that: "informed consent."

It sounds like your doctor is too lazy and in too much of a hurry to "waste" HIS valuable time explaining the options, risks and benefits to the patients ... so he just decides for them (and sends them the bill).

IMHO, highly unethical.

[Terpsichore]

Yep.  Every three to six months.  And you are right, we need to be more clear when the patient checks in as to what a basic exam is.  We can't rely on doctor to actually follow through to explain the reason why he wants to run a field and give the patient an option if they want to have it run or not.  It is better to tell them, "Ok, so here is what I'm seeing in your eyes, I'd like to run X test because of Y reason.  It will be billed to medical insurance and you may get a bill if there is anything left over after they pay and we adjust off what they say.  Based on this, do you have any questions and do you agree to having this run or are you going to decline?", vs the annoyed/irritated/pissed off patient because they got a bill they weren't expecting.  The staff have too strong of a work ethic to let this be an ongoing issue.  Maybe with a change of verbiage, things will balance out so everyone is happy.

[lupinus]

Is this a multi doc practice? Or is it his practice? If it's a group it might not be a bad idea to look into kicking him to the dog house.


Sent from my iPhone. Freaking autocorrect.

[cordex]

I would be a former patient.

[vaskidmark]

Unless I missed it, nobody has yet suggested you consult a criminal defense attorney (accomplice or conspiracy to commit fraud) and see if you bear any serious liability exposure.

Ratting him out is going to involve all sorts of consequences you may not want to experience, thus another reason for an attorney to be shielded by confidentiality privilege.

As to

Are we legally required to inform patients of these tests before hand, or is it doctor's responsibility to inform them prior to running them?

:

You are not "eligible" to obtain informed consent, or even witness the patient signing the informed consent form.  That gets you off that hook.  But the doc is required to get informed consent for anything beyond what your practice advertises as a "basic exam".

Telling a patient to take the matter up with the fraud investigation section of their insurer, or to go complain to the state licensing board still will most likely get your name dragged through the mud no matter how much you tell the patient to not say you suggested they file a complaint.

A closing comment:  it is a matter of conscience; you might want to seek spiritual counseling before you take any steps to clear that up.

stay safe.