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.
Fees at your optometry practice to set:
- General eye examinations
- Contact lens exams
- Other CPT codes for medical procedures and imaging
- Accessory products
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.
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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