Setting Fees at Your Optometry Practice – Free Spreadsheet Included

Setting fees at your optometry practice is never easy.

There are many philosophies on how to set fees at your optometry practice, and we will examine a few in this article. Please keep in mind, I am in no way suggesting what fees you should set or attempting to get a group of optometrists to set their fees at a certain rate. I am just giving you a general insight on the philosophy of setting fees at your practice. The fees you decide to set are up to you.

medicare optometry fee schedule

To make life easier, we have attached a spreadsheet that will help you to do this! You can download it by filling out the form at the end of the article! 👇

Fees at your optometry practice to set:

  • General eye examinations
  • Contact lens exams
  • Other CPT codes for medical procedures and imaging
  • Nutraceuticals
  • Accessory products
  • Frames
  • Lenses

Considerations when it comes to setting fees at your optometry practice:

  • 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

Step 1: Determine what percentage of your patients are insured vs private pay.

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. You can 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?

Oftentimes, most practices will base their fee schedule on Medicare, so we’ll look at that a bit more closely.

Step 2: Look at the Medicare Physician Fee Schedule

Oftentimes, Medicare will offer the highest reimbursement rates when it comes to billing and coding. You can obtain their fee schedule to set yourself up and use that as a guide to base your fees on.

Step 3: Determining How to Set Your Fees

Once you have identified the highest reimbursing insurance company and what they’ll reimburse you (oftentimes Medicare), make sure you set your fees at or above that amount. You can certainly set those fees as high as you want! Remember though, you must consider the fact that your private pay patients will have to pay those fees.

Unfortunately, you can’t just set a global discount for patients because they are private pay, there are some murky legal waters that you’ll need to navigate if you are attempting to do so.

Many offices elect to set their fees a little higher than the Medicare reimbursement rates, which typically won’t create an issue for private pay patients. Then again, if you set high fees and provide a great patient experience, and patients understand the value in coming to you, then perhaps you can set your fees well above these reimbursement rates!

Step 4: List Out Your CPT Codes and Fees For Your Staff

Creating a list that can easily be referenced with CPT code and associated fee will be critical when it comes time to billing and coding, and giving your staff the resource necessary to help patients understand fees and charges.

There’s no magic number when it comes to setting your fees an amount higher than the Medicare schedule. For example, you may choose to mark up a fundus photo at a higher rate than a visual field for example.

The important thing is to make sure you have your fees clearly listed out with corresponding CPT codes.

When it comes to establishing fees for certain procedures – look into your practice demographic.

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 an overly exaggerated example – If you are in an area where 100% of people have glaucoma and 0% of people have ARMD, you might elect to choose a higher % markup on your visual field because people will NEED this and will pay for it. On the other hand, your retinal OCT might not be as much in high demand, and people might be pushing back if you are trying to bill it at an exorbitant 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!

7 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.

  3. Ruth Beck

    As for me, the establishment of payment is always a difficult question, especially if you are just starting your journey. Since the number of customers and how long they will be with you depends on the established payment. This article contains very good and useful tips, thank you!

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