Dare to be Different: Achieve Independence from Managed Care

Joe DiGiorgio O.D.

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I also included a graph with real practice numbers, tracking the growth in gross as I transitioned from taking VCPs to NOT taking them...

Viola did you accomplish your PP growth primarily through the pediatric specialty?
 
Dec 26, 2001
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Viola did you accomplish your PP growth primarily through the pediatric specialty?
partly but not completely. I call my practice "Diapers to Depends." We see patients aged zero to 120 every day.
 

Jeffrey S. Filandro

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Almost everyone who "drops vision plans" says that their gross goes down and their net goes up. Are they talking actual net dollars in their practice or percentage net? Virtually every person I've seen discuss this has been referring to percentage net.

This right here.

The first VCP I drop will be the one that has the perfect combination of 1) low pay 2) slow pay 3) no pay.

When the big plans retro-charge me back for a few eye exam claims from 2018...I curse under my breath BUT realize that you can't let $100K of business go for a single $60 exam chargeback.

It is the small VCP's that pay low...pay slow...and take away the optical profit to the extent that you get negative check after negative check after negative check. But I don't need anyone to explain to me that my gross will go down and my net will go up unless it includes dinner and a show...or a few free CE credits...or a waterbottle...or some other swag that I can give my kids...they really like the phone chargers if any vendors are reading this :)
 
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This right here.

The first VCP I drop will be the one that has the perfect combination of 1) low pay 2) slow pay 3) no pay.

When the big plans retro-charge me back for a few eye exam claims from 2018...I curse under my breath BUT realize that you can't let $100K of business go for a single $60 exam chargeback.

It is the small VCP's that pay low...pay slow...and take away the optical profit to the extent that you get negative check after negative check after negative check. But I don't need anyone to explain to me that my gross will go down and my net will go up unless it includes dinner and a show...or a few free CE credits...or a waterbottle...or some other swag that I can give my kids...they really like the phone chargers if any vendors are reading this :)
My gross did not go down. It went up.
 

AdminWolf

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It's funny, as opened my e-mail this morning I was greeted with this from Medscape (below) -- it echoes what Dr. Steinberg just opined about VSP.

No area of healthcare is immune (and IMO the phrase "Insurance Titan" really, really, should not be a thing...) Looking forward to a fun show!


Insurance Titan Drops Doctors, Needy Patients 'Caught in the Middle'
https://www.medscape.com/viewarticle/925778

BAYONNE, N.J. — For five years, Rasha Salama has taken her two children to Dr. Inas Wassef, a pediatrician a few blocks from her home in this blue-collar town across the bay from New York City.
Salama likes the doctor because Wassef speaks her native language — Arabic — and has office hours at convenient times for children.

"She knows my kids, answers the phone, is open on Saturdays and is everything for me," she said.
But UnitedHealthcare is dropping Wassef — and hundreds of other doctors in its central and northern New Jersey Medicaid physician network. The move is forcing thousands of low-income patients such as Salama to forsake longtime physicians.

Across the nation, business and contractual disputes are separating patients from longtime doctors. This often occurs when doctors don't want to accept the rates insurers are willing to pay. It sometimes occurs when insurers' business plans require having a narrower network of doctors — doctors whose practice patterns may be easier to control.

But in this case, the cause of the exclusion goes to even deeper business connections: Wassef and other doctors say the insurer appears to be trying to shift patients to Riverside Medical Group, a 20-office physicians' practice owned by Optum, a sister company of UnitedHealthcare, both of which are subsidiaries of UnitedHealth Group. UnitedHealthcare is essentially forcing patients to transfer to doctors it controls, the doctors allege.

Indeed, several patients said the health plan directed them to Riverside when informing them their doctors were being dropped.

Lawrence Downs, CEO of the Medical Society of New Jersey, said he estimates UnitedHealthcare is trying to remove hundreds of doctors in central and northern New Jersey from its network. That is the same area where Riverside Medical operates, he noted.

"It seems like they are steering patients away from small, community-based doctors to large groups that they own," he said.

[MORE]
 

susan resnick

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Also I am not sure how Susan & Viola do it, because IIRC, they are both active scleral lens fitters. When looking at sites like "My Big Fat Scleral Lenses" it sounds like if people do not have insurance coverage for their sclerals, many will choose to be visually handicapped rather than possibly think about investing in improving the quality of their lives.

(oops--hope I am not derailing the thread).
Some will go OON some will not. Fewer patients paying more $ is fine with us.
 

Paul Farkas

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Ring: Hello Ms Jones, how can I help you?
Well, I noticed from your excellent website that you specialize in scleral lenses...
Yes Ms Jones we do...why Dr. Panzer has been fitting these for many years and is quite the expert. Would you like to schedule an appointment?
Sure, do you take my XYZ plan..
No Ms, Jones as a matter of fact the doctor does not.

Well, thank you, I appreciate your time..CLICK!

Allan you have spent many years developing your media personality and becoming the "Go to" expert in Houston,TX. Word spreads, so you attract patients from afar including overseas.

Do these patients who come to see "THE" Dr Panzer nickel and dime or worry if you take their Vision Plan?

I hope the Webinar covers the importance of being "THE" OD in your community.
 

Greg Luce

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It's like billing and coding. Most of the so called gurus in our field seem to be right only about 50% of the time.
Maybe because billing and coding are one thing. Getting paid in another. Since some of them don't practice they have no idea if they would ever get paid. They at lease keep trying to learn and pass what they learn along. Or they like getting paid for the lecture and articles. Who knows?
 

Greg Luce

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Sure, do you take my XYZ plan..
No Ms, Jones as a matter of fact the doctor does not.
We can answer that question in other ways. I like your answer because it is true. Another way to answer that is also true is to not use the word No.

"Sure, do you take XYZ plan?"

"we are happy to see you out of network, as Dr. Pazer is doing work that is beyond the scope of XYZ plan may we discuss how that would look for you?"

I am no wordsmith and I certainly don't want to mis-lead anyone and I don't think bait and switch is acceptable.

How does that answer sound? Sneaky or misleading in any way?
 
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Craig Steinberg OD JD

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We can answer that question in other ways. I like your answer because it is true. Another way to answer that is also true is to not use the word No.

"Sure, do you take XYZ plan?"

"we are happy to see you out of network, as Dr. Pazer is doing work that is beyond the scope of XYZ plan may we discuss how that would look for you?"

I am no wordsmith and I certainly don't want to mis-lead anyone and I don't think bait and switch is acceptable.

How does that answer sound? Sneaky or misleading in any way?
Why not just say, yes, we accept it as an out of network provider.
 

susan resnick

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Allan you have spent many years developing your media personality and becoming the "Go to" expert in Houston,TX. Word spreads, so you attract patients from afar including overseas.

Do these patients who come to see "THE" Dr Panzer nickel and dime or worry if you take their Vision Plan?

I hope the Webinar covers the importance of being "THE" OD in your community.
Well stated Paul!! We cover having the CONFIDENCE of knowing you are THE OD in your community!!
 

Greg Luce

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we accept it as an out of network provider.
Because we don't accept assignment OON. We have no relationship with the third party payer at all. I don't want to be misleading, if we did accept assignment OON that would work.

I may be wrong in my understanding of In Network, Out of Network accepting assignment and Out of Network period. Are there three such relationships?
 

Craig Steinberg OD JD

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Because we don't accept assignment OON. We have no relationship with the third party payer at all. I don't want to be misleading, if we did accept assignment OON that would work.

I may be wrong in my understanding of In Network, Out of Network accepting assignment and Out of Network period. Are there three such relationships?
I'd agree, my words work IF you are accepting assignment. If you won't accept assignment of OON benefits, then the answer is no. But a better answer would be, "We are out of network with you insurance, so we will bill them for you and they'll pay your benefits directly to you." (Assuming you'll do the billing for them. If you won't do that, we'll, you're not going to see the patient most likely so I wouldn't worry about the answer you give.)
 

Ken Elder

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Maybe because billing and coding are one thing. Getting paid in another. Since some of them don't practice they have no idea if they would ever get paid. They at lease keep trying to learn and pass what they learn along. Or they like getting paid for the lecture and articles. Who knows?

I think the biggest issue is that what works for Blue Cross of Connecticut does not necessarily work for Blue Cross of Texas. Each insurance plan has their own individual rules and regulations. Absolute nightmare. There's no one standard.
 

Craig Steinberg OD JD

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Bait and switch...

Does my XXXXX insurance cover lasik?

Yes it does...you have a $4000 copay and XXXXX covers the rest.
That's not bait and switch.

Bait and switch is when you draw a patient into the business for one product with the intent of switching them to a more expensive alternative product. In most cases the FACTS will show that you either don't even offer the "bait" or it is almost never actually utilized. It is just bait used to get a "hook" into the unsuspecting customer.
 
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Hi Ken,
I am hoping to answer your question. Our webinar addresses a bunch of stuff related to best practices for “honing” a practice in general, but focuses on “being your own boss” by not accepting a third party’s idea of how much you should charge for your services. Would love you to join us.
As far as your question here, I, too need a better definition of “money for personal enjoyment”. As a preliminary response: our practice is a subchapter S P.C. We take salaries plus quarterly distributions. Our net to the principal partners is roughly 22%
And I am a PLLC and do not draw a salary but rather take profit distributions and draw rental income from my practice as I “lease the space” to my own company.
 
Dec 26, 2001
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I'd agree, my words work IF you are accepting assignment. If you won't accept assignment of OON benefits, then the answer is no. But a better answer would be, "We are out of network with you insurance, so we will bill them for you and they'll pay your benefits directly to you." (Assuming you'll do the billing for them. If you won't do that, we'll, you're not going to see the patient most likely so I wouldn't worry about the answer you give.)
I do see many patients who have both medical and vision plans. You’d be surprised how many are willing to pay for expertise and convenience. We address how to achieve this “convenience” in the webinar.
 

Craig Steinberg OD JD

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I do see many patients who have both medical and vision plans. You’d be surprised how many are willing to pay for expertise and convenience. We address how to achieve this “convenience” in the webinar.
I'm not sure your experience, but mine is that the success or failure of that turns in many cases on the attitude of the doctor. If he/she is negative, defeated, etc., and doesn't really believe in what they are saying, the patients get it and don't come. The doctors that are enthusiastic and sincere are far more successful. I find that you can often tell from the first five seconds... if their first words are, "It'll never work", it almost certainly won't. If their first words are, "Can you teach me how" or something similar, they are often successful.

In ten years the latter group will probably have a thriving private practice, and the former will have sold for 50 cents on the dollar or just closed up and retired.
 

Allan Panzer

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Dec 26, 2001
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I'm not sure your experience, but mine is that the success or failure of that turns in many cases on the attitude of the doctor. If he/she is negative, defeated, etc., and doesn't really believe in what they are saying, the patients get it and don't come. The doctors that are enthusiastic and sincere are far more successful. I find that you can often tell from the first five seconds... if their first words are, "It'll never work", it almost certainly won't. If their first words are, "Can you teach me how" or something similar, they are often successful.

In ten years the latter group will probably have a thriving private practice, and the former will have sold for 50 cents on the dollar or just closed up and retired.
I think you’re mostly correct but I also believe that attitude adjustments are d rudely possible if doctors can be shown that there is a light at the end of the tunnel. This is our intent- to demonstrate what is possible. One large established practice, one small first generation practice, both successful and happy.
 
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Greg Luce

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I'd agree, my words work IF you are accepting assignment.
Just as I thought, good.

Now, do tell, how does one who is Out Of Network and not accepting assignment bill on behalf of a patient that leads to the patient being reimbursed? Is this what you are indicating in this recommendation?

We are out of network with you insurance, so we will bill them for you and they'll pay your benefits directly to you." (Assuming you'll do the billing for them.
 

Craig Steinberg OD JD

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Just as I thought, good.

Now, do tell, how does one who is Out Of Network and not accepting assignment bill on behalf of a patient that leads to the patient being reimbursed? Is this what you are indicating in this recommendation?
You just don't check the "accept assignment" box. They'll send the check to the patient. Doctors that do the billing are doing it as a courtesy to the patient since we're a lot more able to complete a CMS1500 than a patient is. We know the codes, etc. So, we complete the CMS1500 and send it to the appropriate address for OON claims for the payer.
 
Dec 26, 2001
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Just as I thought, good.

Now, do tell, how does one who is Out Of Network and not accepting assignment bill on behalf of a patient that leads to the patient being reimbursed? Is this what you are indicating in this recommendation?
I can and do submit claims for patients all the time. Assuming they’ve met their deductible and have out of network coverage, they get reimbursed quite well.
 

Jeffrey S. Filandro

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My gross did not go down. It went up.

That's a very good topic for a webinar.... ;)

I know the metrics of my two private and one corporate office. When the day comes for me to "drop" my first VCP for XXXXXXXX reason.... I will be later be able to decide to 1) to start taking it again or 2) drop the next low hanging fruit.

The hardest part of building a primarily VCP dependent practices with a side order of medical optometry is most patients think that the MAIN job of an optometrist is to provide an eye exam for glasses of contacts under their insurance.

We may want to 1) perform LPI's, Lipiflow, PRK and treat medical all day without using a phoropter...but my patients want me to 2) perform a routine exam for a Zero dollar copay.
 
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Jeffrey S. Filandro

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That's not bait and switch.

Bait and switch is when you draw a patient into the business for one product with the intent of switching them to a more expensive alternative product. In most cases the FACTS will show that you either don't even offer the "bait" or it is almost never actually utilized. It is just bait used to get a "hook" into the unsuspecting customer.

We can agree to disagree.

People that go to ABC for "two for 99" and after ordering glasses they hit the counter to "that will be $478" to me is bait and switch.

Going to have lasik using a VCP is the same thing. "Doc I want to have lasik using my insurance"...if you don't tell them that it is still $4000 out of pocket they will be better off going to Lasik Plus for PRK $500 an eye.

same bait (price or being able to use insurance) ......different service (lasik/PRK/ICL)
 

Jeffrey S. Filandro

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Bait and switch is when you draw a patient into the business for one product with the intent of switching them to a more expensive alternative product.

But the real everyday use of "bait and switch" in medical optometry is the "vision vs medical" discussion that we give every VCP patient when the exam gets converted in the chair to medical.

It is not a coincidence that the "more expensive alternate testing" pisses off every patient because they did not want dry eye, diabetes, HTN, cataract, glaucoma or that pesky bitemporal VF screening defect....

They wanted glasses.

I am not judging right or wrong...vision or medical...bait vs switch...but each OD that takes vision and medical has their own idea on the "best way" to "address this".
 

Joe DiGiorgio O.D.

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I am not judging right or wrong...vision or medical...bait vs switch...but each OD that takes vision and medical has their own idea on the "best way" to "address this".

Paging Dr. Pagan.
 
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Greg Luce

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You just don't check the "accept assignment" box. They'll send the check to the patient. Doctors that do the billing are doing it as a courtesy to the patient since we're a lot more able to complete a CMS1500 than a patient is. We know the codes, etc. So, we complete the CMS1500 and send it to the appropriate address for OON claims for the payer.
Thank you.
 

Greg Luce

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reimbursed quite well.
I have yet to see that. Medical claims perhaps. Vision Care Plans, reimbursed quite well would not be how any patient I have seen OON and they go reimbursed would call it. That may be regional?
 

Craig Steinberg OD JD

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But the real everyday use of "bait and switch" in medical optometry is the "vision vs medical" discussion that we give every VCP patient when the exam gets converted in the chair to medical.

It is not a coincidence that the "more expensive alternate testing" pisses off every patient because they did not want dry eye, diabetes, HTN, cataract, glaucoma or that pesky bitemporal VF screening defect....

They wanted glasses.

I am not judging right or wrong...vision or medical...bait vs switch...but each OD that takes vision and medical has their own idea on the "best way" to "address this".
I don't consider the lack of understanding how the vision/medical dichotomy works (or even its existence) that our patients have to be a bait and switch. The truth is, WE don't make these rules. WE are obeying them. When VSP says they don't cover a problem, and the patient tells us they have that problem and would like it addressed, that's not bait and switch in any form. That's us saying, okay, well, BECAUSE OF THE RULES OF YOUR INSURANCE, that means we shift from one contract to the other.

I'll use a weak analogy. Store X advertises a $9 widget. They do have and sell $9 widgets. Consumer enters store and sees big signs also selling $200 TV's. So, they buy their widget, but also a TV. Or maybe they decide, heck, I need a TV more than I need a widget. There was no bait and switch there in my opinion.
 

Joe DiGiorgio O.D.

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I'll use a weak analogy. Store X advertises a $9 widget. They do have and sell $9 widgets. Consumer enters store and sees big signs also selling $200 TV's. So, they buy their widget, but also a TV. Or maybe they decide, heck, I need a TV more than I need a widget. There was no bait and switch there in my opinion.

A customer gets an email saying that the local tire dealer is doing low cost tire rotations. She brings in her Lexus SUV and they put her vehicle up on the hoist, the tech does a quick tire inspection and they advise Mrs. Jones that she is below the safe tread level and best practices indicate it is time for replacement. She gives the nod to replace the baldies with a new set of Pirelli's, she gets for new 4 new TPMS sensors, has the tires power spin balanced, and has them nitrogen filled. In under 30 minutes she pulls away with her sweet rig as she puts $1,450 on his Visa card, and gets the miles.

Was that bait and switch or good care for her Lexus?
 

Craig Steinberg OD JD

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A customer gets an email saying that the local tire dealer is doing low cost tire rotations. She brings in her Lexus SUV and they put her vehicle up on the hoist, the tech does a quick tire inspection and they advise Mrs. Jones that she is below the safe tread level and best practices indicate it is time for replacement. She gives the nod to replace the baldies with a new set of Pirelli's, she gets for new 4 new TPMS sensors, has the tires power spin balanced, and has them nitrogen filled. In under 30 minutes she pulls away with her sweet rig as she puts $1,450 on his Visa card, and gets the miles.

Was that bait and switch or good care for her Lexus?
I think good care. But I'd change that slightly. Instead of noting the tires need replacing the tech notes that the transmission is leaking. He advises her and she says, well, fix that too. So he rotates the tires and does a transmission repair, and bills for both.

If a patient comes into our office with their VCP plan in hand, because they sat on their glasses, and they've got 30 IOPs and .8 cups, it is NOT bait and switch to say, oh, by the way, you may be going blind and we need to evaluate you for what appears to be glaucoma, but that's not covered by your VCP plan.

And, while we don't wish glaucoma on anyone, ONE of the reasons we TAKE that VCP plan is the expectation that some of those VCP patients will have other problems that also need care.
 

Richard Pagan

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It is that crazy idea that performing Optometry for a living is beneath an Optometrist.

that depends on how you define "optometry". If your definition is the usual limited care refractive type exams then I disagree. I prefer proper care.
 
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Richard Pagan

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Was that bait and switch or good care for her Lexus?

bait and switch is bad for you, bad for the pt, etc. Honesty is the only way. The problem is OD's are afraid of being honest. They rationalize to the bitter end, they defend nonsensical "routine exam" crapola, and they stink of fear.
 
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