Setting Fees at Your Optometry Practice – Free Spreadsheet Included

Setting fees at your optometry practice is never easy. I attached a spreadsheet that will help you to do this. There are many philosophies on how you will set your fees, check out a few in this article.

medicare optometry fee schedule

Fees to set

  • Eye exam prices
  • Contact lens exam prices
  • CPT codes
  • Nutraceuticals
  • Accessory products
  • Frames
  • Lenses

Considerations to setting fees

  • Private pay patients
  • Vision insurance patients
  • Medical insurance patients
  • Fees must be the same for every patient, you cannot have different patients pay different prices
  • The percentage of each type of patient your office sees

First off, you need to determine what percentage of your patients are private pay vs. insured. Then find out what your highest insurance plan is reimbursing. Just call them and get their fee schedule for a range of CPT codes. You never want to set your fees lower than what the insurance plan is willing to reimburse to you. Why would you take less than what they are offering?

Personally, I found that Medicare was offering my office the highest reimbursement rate here in California, so I got their fee schedule and set my fees based on that. You can get your medicare rates in your area here.

Once you have the highest fees an insurance company will provide, make sure your fees are at or above that amount. Next, you must consider the fact that your private pay patients will have to pay these fees. You can’t do a global discount just because they are private pay, that is illegal to my knowledge.

At my office, we set our fees higher than Medicare reimbursement rates and private pay patients do not mind paying this. They feel our practice and our doctors are absolutely worth the money spent.

We set different CPT codes at varying fee rates. For example, a fundus photo is a higher markup rate than visual field is.

Think about it like this…. If you have a private pay patient, what are they coming in for? Which types of CPT codes will you likely be billing? Here is a overly exaggerated example – If you are in an area where 100% of people have glaucoma and 0% of people have ARMD, you can get away with charging a higher % markup on your ONH OCT because people will NEED this and will pay for it. On the other hand, your retina OCT is not in high demand and people may push back if you are trying to bill it at a high amount. That is a very oversimplified example, but something important to keep in mind.

An example of high vs low paying CPT codes

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About Matt Geller

Matthew Geller
Dr. Matt Geller is a technology entrepreneur with a track record of developing successful online platforms to solve problems in the healthcare space. Matt is an optometrist in San Diego and is the founder of OptometryStudents.com, NewGradOptometry.com and the co-founder of CovalentCareers.com!

5 comments

  1. Hey Matt! Question for you: when you are looking up the fees in Medicare’s Physician Fee Schedule, what prices are you looking at exactly? Non-facility vs facility, price vs limiting charge? Thanks in advance!

    • Matthew Geller

      Hey @ahanna05 – great question. Here are some overall definitions to help you on your quest to decipher the Medicare fee schedule…

      My office uses the NON-FACILITY column.

      LIMITING CHARGE: this is equal to 115 percent of the fee schedule amount and is the maximum the
      nonparticipant may charge a beneficiary.

      FACILITY PRICE: This is the fee schedule amount when a physician provides this service in a facility setting, such as a hospital or Ambulatory Surgical Center (ASC).

      NON-FACILITY PRICE: This column includes the fee schedule amount when a physician performs a procedure in a non-facility setting such as the office.

      Generally Medicare provides higher payments to physicians and other health care professionals for procedures performed in their offices because they are responsible for providing clinical staff, supplies, and equipment.

      NON-FACILITY LIMITING CHARGE: This is the maximum amount a beneficiary can be charged for the service: By nonparticipating health care professionals; Who do not accept assignment; and When the service is performed in an office setting

      I hope this helps!

  2. I have a question about the cash discount. I understand the quote from Medicare but I really don’t think it clarifies much. My question is how much of a cash discount can you give? So the cpt code has to have the same charge but if you can discount 75% then that is a pretty easy way to get around that rule.

    • Antonio Chirumbolo

      I think someone will be able to clarify this better than I, but I do believe there is a certain limitation to cash discount, meaning you couldn’t discount it down 75%. However, I could be wrong. We’ll seek some advice from the billing gurus and get right back to you.

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