Medical Model

Build Medical Eyecare Services with Well-Considered Consults

By Diane Palombi, OD

Sept. 14, 2016

Sending a patient to a specialist for a consult, or additional testing, sometimes is necessary to ensure the patient receives the best care possible. However, in this era of high insurance deductibles, it is also important to consider whether the additional doctor visit and testing is essential.

The OD is put into a balancing act: Ensure the best care vs. safeguarding that the patient isn’t unduly stressed financially.

It is important to get patients the care they need, whether from you, or from a specialist. But with many of your patients’ insurance plans requiring deductibles to be met before the insurance will cover additional care, you need to educate patients about the importance of visiting the specialist you would like to send them to. And you need to carefully consider whether it is a necessity.

Thirty years ago I had no reservations about sending my patients to a specialist for a consult, or for additional testing. Occasionally a patient would express concern that their insurance only paid for one eye exam a year. My response was that they had a medical issue, so their medical insurance would cover the specialist or procedure. If I could not get a patient to see 20/20, and felt certain that there was no refractive cause, binocular vision issue, or obvious medical problem like cataracts, I would send the patient to an ophthalmologist to rule out pathology. It was better to be safe than sorry.

Medical insurance premiums back then were more affordable to the employer. In turn, they provided insurance plans with low or no co-pays and covered additional exam procedures. Now you have to educate your patient that the specialist and additional testing are important–important enough to possibly pay out-of-pocket fees for. As time has progressed, insurance premiums have increased to the point that employers often provide insurance plans with high deductibles that need to be met before the employee does not have to pay for a procedure out of pocket.

For a healthy or young employee who has to pay part, or all, of their insurance premium, this high deductible is preferable to paying high insurance premiums. They are willing to roll the dice that they will not need procedures during the year that will offset the difference in premium cost savings of a high- versus low-deductible plan.

The premiums of these low-deductible plans can be pricey. I have a friend who pays $1,500 a month for her plan. She wants the peace of mind that any medical procedure that she could require would be covered by insurance. The platinum coverage is worth the money to her.

I decided to go middle of the road since my spouse and I are usually healthy. My plan has a moderate deductible of $2,000. It covers a physical every year and other preventative tests. I also can have several office visits to the doctor that are covered by co-pays. However, if I need lab work, X-rays, or other procedures, it goes to my deductible first. There are plans available where the patient may have deductibles that approach $7,000. Another consideration is the out-of-pocket maximums that can be even higher.

Doctors now need to make wise consults to specialists, or for additional medical procedures. Perhaps a better plan is to repeat a test that you think is suspect. That new piece of optometric equipment that you are making payments on may not be necessary for every patient who comes in for a routine exam. A drug that you prescribed may not be covered under your patient’s plan, so it may be necessary to switch to a different one. It is easy to send for a consult, or order additional tests, when you know that you are billing an insurance company. That is not always the case now. If a patient spends his hard-earned cash on a consult or procedure that turns out to be unnecessary, they are not going to think too favorably on you.

It is hard walking the tight rope of protecting yourself from a potential lawsuit–and protecting your patient–and being too cautious and ordering a battery of unnecessary tests. Every situation is different. There is no cookbook method of deciding when you should just monitor a condition versus ordering additional care. Being knowledgeable about your patient’s medical insurance, and just not their vision insurance, will help you better make those decisions. This is especially true if the patient will be faced with a potentially large medical bill that they will be paying out of pocket.

Patient care is our top priority. If a patient needs additional testing, or the expertise of a specialist, money should not be an issue. Just be certain that additional care is truly necessary.

What have you learned about when to send to a specialist, and when to continue managing a patient’s condition yourself? How does your practice build relationships with other local health care providers to ensure patients receive the best overall care?

Diane Palombi, OD, now retired,owned Palombi Vision Center in Wentzville, Mo. To contact her: dlpod1@hotmail.com

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