If optometrists of your parents generation took a look at your practice, they might think it was something out of a science fiction movie. The changes that have taken place in such a short time in our profession have been nothing short of remarkable.

For example, just 20 years ago, not too many eye-care practitioners would have believed that we would have lasers in our offices, not to mention the ability to prescribe pharmaceuticals and, in a few states, even surgical privileges.

But, with the medical model of optometry comes new challenges. To fully comply with state and federal health-care regulations, many
doctors have had to redefine their practices and change patients perceptions of their practices from an optical dispensary to a medical facility. Others have opted not to fully implement medical eye care due to the various stresses involved with changing practice modes.

To many practitioners, transitioning from refractive care to full-scope medical care is so overwhelming that they approach it haphazardly, which may result in coding and billing errorsnot to mention frustration for the doctors, staff and patients.

Improper implementation can significantly disrupt patient care and could possibly put both the practice and the doctor at risk. This could include anything from an incorrect diagnosis, to a charge of malpractice, to financial worries and cash flow concerns. Successful transition to medical eye care requires careful planning and long-term goal setting. Three questions must be addressed prior to transitioning to medical care:

How much medical eye care am I comfortable with?

What are my liabilities?

How will this affect my current practice mode?

Integrating medical eye care into your practice does not mean abandoning our refraction roots, but simply adding value to what we already offer. It allows optometrists to provide valuable services to the community, and it allows patients to have a wider range of options when seeking medical eye care. Not to mention, implemented properly, medical eye care can also be a significant revenue source and practice builder.

Go Medical

Enhance your diagnostic and treatment skills.

Have the proper instruments and pharmaceuticals available.

Educate and train your staff.

Adjust your appointment schedule.

Become proficient at billing and coding.

Have a reliable electronic medical records and office management system.
Network with other health care professionals to garner referrals.

Ready for Medical?

First, assess your diagnosis and treatment skills. If you are not comfortable diagnosing and treating eye disease, take whatever courses are necessary to raise your skill and comfort level. Know your level of competency, and work to keep improving it, but keep in mind that no one knows it all; there will always be challenging cases. If the case in front of you is beyond your comfort zone, dont be afraid to refer the patient to a colleague who has more experience with such cases.

Next, outfit your office with the proper tools for diagnosis and management of eye disease. These include appropriate diagnostic and treatment pharmaceuticals for in-office treatment of many common eye problems. If drug reps do not visit your office regularly, call the companies and ask for samples of the drops you need. Many companies will simply fax you a form that you can sign and fax back with your license number to order your samples. Keep an inventory and have a staff member monitor the expiration dates. Remember to reorder new drops when necessary.

Also, proper diagnosis requires the proper instrumentation. If you cant have the right tools in your office just yet, make sure that you have access to them. Hand-held instruments (e.g., spuds, forceps, lenses and burrs) for foreign body removal and most
common presentations of red eyes are relatively inexpensive. These instruments can be easy to obtain and inexpensive to maintain. Instruct your staff on the proper disinfection and storage of them.

The diagnosis and treatment of more complex diseases and conditions generally requires more sophisticated, state-of-the-art instrumentation, and so, greater expense. Today, the effective diagnosis and management of glaucoma, for example, requires at least a tonometer, pachymeter, threshold visual field analyzer, gonioscopy lens and perhaps optic nerve head and nerve fiber layer analyzersnot to mention samples of the meds you will be prescribing.

In the beginning, before your medical practice picks up, you may not be able to justify the expense of many of these and other high-tech instruments. Cost-sharing can be an effective means to have access to high-cost, high-tech instruments without bearing the total financial burden yourself. Creative O.D.s have teamed up to purchase instruments that they share between their offices. 

Not long ago, two of my neighboring optometrists both wanted a GDx (Carl Zeiss Meditec) in their practices, but each independently could not justify its cost. So, they came to an agreement in which they split the purchase price of the instrument and transport it between the two offices weekly. Each practices patients only have to wait a maximum of one week for testing, and the optometrists both have access to the technology as necessary.

But, in some cases, it may be impractical to transport an instrument. In such cases, its better to designate which office will house the technology and simply share access and usage. This type of arrangement may tend to benefit the first practice, but both practitioners will still be able to access and use the equipment.

Once youre confident of your skills and have properly equipped your office, youll need to bring your staff up to speed on medical eye care. The first thing they need to know is the difference between vision and medical insurance. Dont assume your staff knows the differences.

Know Your Liabilities

Have a staff meeting or two to go over the distinction between vision and medical insurance. Illustrate different scenarios that may occur and how to handle them through examples or role play. For example, if a patient comes in for an eye exam and presents his or her vision insurance card, but is subsequently diagnosed with a medical eye condition that requires further testing, which insurance should be billed and how? The opposite could also occur: Patients may present with medical concerns, but only need a proper refraction to solve the problem.

Your staff members need to know how to explain the different types of insurance to patients and how they work regarding medically necessary visits vs. routine vision care. Youll find that many patients are confused when it comes to their insurance and not only dont know the differences, but also dont realize that you accept their medical plans (e.g., Medicare).

Also, your staff members need to learn how to triage phone calls. In medical cases, your patients call for more than just their yearly checkup.

Decide how youd like to schedule medical visits vs. refractive appointments. Make sure that staff membersespecially those who schedule your appointmentsknow and understand your system. With experience, you and your staff will develop an understanding of the amount of time needed for a medical exam vs. a refractive exam. Discuss with your staff how much is too much, though; you dont want to be overburdened and unable to give each patient the time he or she needs! The staff also needs to know the difference between an emergency and an urgency, and the difference between a refractive and a medical request. Asking the right questions during the phone call assures that the patient is seen at the appropriate time by the appropriate person, with as little disruption of the days schedule as possible.1

Training is imperative for proper phone triage. Again, citing examples is a good way to explain the different types of calls employees can expect. Paraoptometric education can be found at many optometric CE meetings and is a great way to raise the bar for your staff.

As your staff members become more adept at managing these patients, they will learn to create a schedule anticipating medical visits and the blocks of time required for them. This goes a long way toward keeping your schedule reasonable, giving you time to effectively examine, diagnose and treat every patient with the attention he or she deserves.

But, be mindful of necessary scheduling modification, as well. For example, when we first detect a medical problem, many feel that it is necessary to perform all the testing at the current visit. Although it may totally disrupt the days schedule, this approach is necessary in cases in which a delay in diagnosis or treatment could ultimately cause vision loss. For less severe diseases and conditions, schedule further testing for another, more convenient time for both the doctor and patient. This way, the patient will be prepared for the test, and the doctor will have the time necessary to fully evaluate the patient and the test results.

This delay between initial exam and follow-up testing also allows for proper investigation of the patients insurance options and explanation of any out-of-pocket expenses that the patient may be responsible for. Many patients have been told that their insurance pays for everythingand in most cases, this is far from the truth. This distinction needs to be carefully explained to patients so they are aware of their financial responsibility.

Staff members are invaluable during the pre-examboth when handling insurance questions and taking a pertinent patient history. Asking the right questions goes a long way toward helping you properly diagnose and treat the problem. Train staff to follow logical lines of questioning to drill down to the most relevant information. For example, if a patient complains of a discharge from his or her eye, your staff needs to respond with the appropriate questions regarding duration, associated symptoms, medications used, etc. The more information you have, the more accurate your diagnosis (and treatment options) will be.

Consider having staff members assist in certain procedures, such as eye lavage, foreign-body assessment, instilling drops and other procedures they are qualified to perform. These staff members need to be specially trained to accept that level of responsibility, but having their abilities at your disposal for these procedures and tests frees you to perform more advanced tasks and to manage your time more effectively.


Properly Code for Medical Procedures

Coding and billing may be the two most important factors in creating a sustainable medical practice. Correct coding creates a revenue stream commensurate with your exams, which in turn enables you to support the medical side of your practice. Incorrect coding can lead to poor or inaccurate reimbursement (at the least) or an audit (at the worst).

You may even want to consider hiring a dedicated billing and coding staff member. Having one person who can keep up with the constantly changing coding and billing regulations not only ensures cleaner claims and faster reimbursement, but also frees you and your other staff members to perform regular patient care duties more effectively. But, be careful. If you do entrust a staff member with this responsibility, you must be absolutely certain of his or her honesty, ethics and integrity. Also, make certain that you institute procedures that give you oversight of the process, in the event of any complications. (See How to Deal with Sticky-Fingered Staff, February 15, 2008.)

Another option: Most practice management or electronic medical records (EMR) software has some coding functions already programmed in to help you choose the proper level of care provided. But, just as when you employ a dedicated coding staffer, be cautious. Ultimately, you are responsible for the codes you submit and fees associated with them.

If youre confused about the complexities of coding, take advantage of available seminars all across the country that deal with this topic. Effective coding is worth the time and effort required to attend one or more of these seminars.


Networking for Success

Having a good referral network enhances your medical practice by integrating your skills with others. One way to seek out other practitioners is to ask your patients who their general practitioners are and whom they respect. Or, ask colleagues for recommendations. Meet up individually with these folks for lunch or coffee, and see if you could potentially network, should you need to refer a patient out or they need to refer one to you.

Many cases will require referral to other specialties. Some will involve entrusting the patient fully to the next level of care, while others will find you comanaging patients to attain the best outcome. Mutual respect will maintain these relationships, whether they are with other O.D.s, ophthalmologists, general practitioners or specialists.

In addition to a referral-out network, a good referral-in network enhances your medical practice and brings in new patients. When building this network, seek out those doctors in your area that have not incorporated medical eye care into their practices and encourage them to refer those patients to you. But, make it very clear to these optometrists that you will not be stealing their patients.

To quell such fears, convince those doctors that your intentions are genuine. They need to know that youre only interested in the medical care of their patients, and will perform only the necessary examination and treatment to address the problem at hand.

In this document, which should be hand-delivered by you to the doctor from whom you hope to receive referrals, explain that all referrals are appreciated, and that the referring O.D. can be actively involved in the continued patient care regimen to the level that he or she desires.

Assure the referring doctor that the patient will be seen only for the referred condition and returned with a complete report when treatment is completed. Additionally, all requests for routine eye care, glasses, contact lenses and the like will be directed back to the referring eye doctor. In such circumstances, you must consider yourself a secondary care provider in order to build a relationship of trust with the primary-care optometrist.

In my office, weve instituted a Red Jacket policy (suggested to me by Mark Boas, O.D., of Exton, Pa.) that helps to address any such concerns of doctors who refer to us. The policy takes its name from the red folder the patients file is kept in, distinguishing it from the others.

Keep the lines of communication open at all times, and offer frequent praise to the doctor and staff for making these timely referrals. This level of commitment is important in maintaining this type of relationship. Once other O.D.s feel comfortable with your referral policy and secure in the knowledge that youre not stealing their patients, youll start to see more medical patients coming your way.


Putting all of this in place will most certainly require some careful planning. But, youll be providing the highest level of care for your patients, and this care and the growth in your practice will offset most of the inconvenience. Most importantly, though, youll be among the many optometrists raising the levels of capability and competence within our profession.

Dr. Diecidue is president of Mountain Computer Systems. He practices in Stroudsburg, Pa.


1. Diecidue AS. Phone triage. SECO International, LLC. Available at: www.secointernational1.com/webce/ aopoverview.cfm?Folder=triage (Accessed January 2008).

Vol. No: 145:09Issue: 9/15/2008