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I have been exploring the option of accepting Medicaid in my practice. I have been told by some not to bother because the reimbursement is so low. Anyone can look up the reimbursement rates on the Utah state website. I’ve compiled the ones I expect to commonly use into a spreadsheet and compared them to Medicare’s reimbursement rates. Keep in mind that Medicare typically sets their rates at 60-80% of the average usual and customary.

The first thing you will notice is that UT Medicaid reimbursement is ridiculously low. Now, take the time to read the vision provider manual at the UT Medicaid site.

If you are like me, then you will have some questions. Here are the ones I had. Can any of you answer them?

1. Can I be a provider of Medicaid optometry services but not bother with providing Medicaid frames and lenses? I’m asking this because I may not be able to break even with thier reimbursement for materials.

2. Does Utah Medicaid have a lab I should use or would I be expected to find some ridiculously cheap frames and lenses to dispense? Oregon has a Medicaid optical lab where all Medicaid orders are processed. The doctors don’t lose money on materials, and they can charge Medicaid a dispensing fee.

3. The example of a frame upgrade in the manual was: normal price $35. Upgrade $50. Medicaid reimbursement $27.50. Is it okay for me to find some frames that I sell for $27.50 and dispense them to all Medicaid patients? I have heard stories of opticals using frames they can’t get rid of (i.e. discontinued models, ugly frames) as their Medicaid frames. Then they use an in-house lens grinder and put cheap plastic lenses with only a single side scratch coat into the frame. Is this okay? Pretend I only have ugly, BC frames for 27.50. The rest of my stylish frame selection runs around $100-$300. If the patient wants anything fashionable, then they’d be forced to upgrade and pay the difference themselves. So, why would I have any frames in the low price range other than 27.50?

4. Does the state of Utah honestly expect $27.50 frames to last two years? Seriously!

5. Can I opt to see only Medicaid children, not adults? I can see as many as 3-4 children in one hour, whereas adults take longer (they have more problems and love to orate about what a shock it is that ever since they turned 43 they can’t see up close anymore), so I can only see 2 per hour. If I’m getting so little reimbursement (39.29 on an S0620), then why not earn more money per unit time?

6. Can I opt to see only blue card recipients and not purple or yellow? From what I understand, blue card allows me to bill Medicaid $30 and any difference between 30 and my usual and customary can be charged to the patient. With Purple and Yellow, I have to accept Medicaid’s assignment as payment in full. Why would I want to see anything but blue card patients?

7. Why does UT Medicaid require refraction be included with 92004 and 92014 when that is not the definition of these services in the AMA’s cpt code manual? This question could be asked of most vision insurance companies. I believe the reason lies in getting something for nothing.

8. Why does Medicaid not pay for polycarbonate lenses for minors when that is the standard in the entire eyecare world? I believe the answer will be fiscal-no concern for trauma prevention.

9. Why is pachymetry (76514) not a covered procedure? Even Medicare pays 11.04. It’s only standard of care for not only Glaucoma, but many acute corneal conditions.

10. Why is the reimbursement for 92060 (VT Diagnostic exam) and 92065 (VT progress exam) set at the ridiculously low price of $5.32 and $4.13? Even Medicare, which typically reimburses 60-80%, pays $50.43 and $31.83. Do you think it’s ethical of me to know how to treat vision therapy conditions, do so regularly on patients with other insurance, but refer out a Medicaid patient because the reimbursement would cause me to lose money? The overly low reimbursement for VT services really chaps my donkey. They are forcing us to be unethical if we decide to be a provider because who in their right mind would accept 5-10% of their usual and customary as payment in full? The assignment is so low you would lose tons of money to try VT on a Medicaid patient.

Anyway, this is just the start of my concerns about becoming a Medicaid provider. I talked with an OBGYN physician once, and he says that for him, seeing Medicare and Medicaid is his charity work.

Another thing I don’t think is fair: How do you explain to your private pay patient that your exam really is worth the $85-100, but at the same time accept $35.50-39.19 as payment in full from a Medicaid patient?

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For those of you consider PM and EMR in your ECP practice, I’d give Officemate a look. I am. A cool feature about their support service is that they not only have an online knowledge base, the knowledge base comes with an RSS feed! Very cool. Officemate must be one of those progressive companies.
I noticed they recently redesigned their website. At first they didn’t have up any barcode scanner partnerships, but now I see they have it back, including one that is bluetooth wireless, so you can walk around the room scanning stuff.
I don’t know why they partner with a tablet PC company if in their hardware specs they state that wireless computing is not recommended. I plan on implementing some of my computeres as wireless, so I’ll let you know how that goes.
Yes, right now I am planning on buying officemate. It’s been a long road of research, but for the money, I get the most features with officemate. I just hope the add-ins like barcode scanners and the box for integrating pretesting equipment doesn’t throw the savings out the window.

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Actually, I love retinoscopy. I find that for me it is more accurate on kids than the autoRx. Anyway, an alert Optiboarder happened upon this [broken link- does anyone know where it is now?retinoscopy simulator. Since it’s in Spanish, allow me to translate.

The green circle on the left side is a spherical plus lens, the left red circles are minus lenses. To actually put the lens in front of the eye, you must click on the circle you want. The middle number is the retinoscope’s light orientation in degrees. The red and green circles on the right are minus and plus cyl respectively. Obviously, those of us belonging to the primary eye care profession won’t have need for the plus cylinder. Adjust the minus cylinder axis in front of the eye by clicking on the red circle to put it in play, the click on the little 3-circle-icon below it until it orients to where you want it.

The dice are to generate random patients. If you want to test yourself, then close both of the eyes by clicking on them.
If you want to generate an Rx yourself to see what it looks like, then you can adjust the controls by first clicking on the type you want, Myopia, Hyperopia, SMA, CMA, SHA, CHA, and mixed (in that order) then press the up and down buttons next to sphere, cylinder, and axis (in that order). The astigmatism value is limited to a maximum of 6D. I’ve personally seen patients with 7.50, but I suppose they are simulating a phoropter without the accessory lenses.

In the lower right corner is the working distance adjustment. If you normally use the R +1.50 lens in the phoropter, then leave the “Compensacion por distancia de trabajo” at zero. But if I wanted to simulate skiascopy racks, then I’d put my working distance at 1.50, and then I would only use the spherical lenses on the left.

Anyway, I thought this might be useful for optometry students to hear about. It also looks cool.

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I’ve recently become aware of a site for opticians, www.opticiansfriend.com, because the site administrator left some comments in this blog. I really like this site. He’s got a lot of information pertinent to optometry. The site has a blog and a forum. It’s also got a good iseikonic lens calculator. In the two years I’ve practiced, I actually did that once for a guy who had cataract surgery in one eye, but wasn’t eligable to get it in the other eye yet. In IHS I couldn’t do contact lenses. I saw there was a proprietary software solution out there, so I just demo’d it and made some pretty funky looking lenses! But hey, they worked and the patient was happy that he didn’t see double any more.
Anyway, Mr. Cordova has a very nice site, and I encourage everyone to check it out. I’m subscribed!

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I just took a MaximEyes online demo today. They sent me a demo CD last week, and I was interested, and so I agreed to have the online presentation. They have some nice functionality.

VSP calculator. I once worked as an optician for exactly one month in Hillsboro, OR. Everyone in Hillsboro has VSP because everyone works for Intel. When ever someone asked me how much their glasses are going to cost them, I had no idea. VSP has an infinite amount of plans and coverages. Once they decided what frames and lens options, then we’d get out the tables and eventually be able to tell them. Well, what happens if they decide that, I’d rather change this option, how much is that? Well, here we go again. With MaximEyes, it’s easy. Just click on the options, press a button and there you have it. What to price a different lens option? No problem! I’d be happy to. Click. Click. There you are.

Electronic interface with EyeFinity for VSP authorizations. Very nice. No waiting on the phone going through some phone tree.

EMR has a very slick feature. Let’s say you see some lattice in the peripheral retina. You diagram it with their drawing tool. It has a little picture that represents lattice that you can drag onto the fundus drawing. Once you drag that on there, it automatically adds the ICD-9 code to your superbill. Sweet! And guess what, completely customizable. I can create my own little picture and assign it an ICD-9 code! Wow.

They also allow you to completely customize the layout of your exam view. Don’t like where the keratometry box is? Move it anywhere you want. Want to keep track of some data point that isn’t already on Maximeyes, there is a way to go create it. Think of the possibilities for research! Pretend you went back in time and no software out there kept track of central corneal thickness, but you wanted it. MaximEyes allows you to create new fields to keep track of in your database.

Your printed reports are completely customizable. Very nice.

They also have a service that if you pay ~$500/year, your patients can go to your website and enter in all their history/welcome form. The data automatically gets populated in your database. What a huge time saver!

Basically MaximEyes addresses most all of my requirements, except price. Call them for a quote, but it’s in the 10-18K range depending on how many work stations you require. Also it costs 2600 per year for support and updates. Ouch.

The consultants will tell you that software is like buying another piece of equipment; however, there is a large discrepancy in price between the low, mid, and high end software solutions. I hate to buy the most expensive, if something half as much will only inconvenience me a little. I will say that if I was planning on having most my business with VSP patients, I would go MaximEyes for sure.

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I’ve been demo’ing about every ECP PMS and EMR solution out there. Can anyone say “lousy user interface?” First of all, I think more of these software companies should be hiring graphic designers. Think Apple. Think pretty. Think cool.

I’ll name names. RLiSYS and eyecareconnect.com have the most boring looking GUI out there. It is so windows95. In this post iPod era we need styling. Sure it might take more beefy computers, but nowadays we have those available.

Second, a big pet peeve is having to demo a product with an online presentation. I can’t remember the next day half the stuff from the presentation (a.k.a. high pressure sales technique). I’d rather have a demo CD to play around with. Then if I like it and if the price is reasonable, let’s do an online presentation to answer more prepared questions. I’ve wasted too much time demo’ing online for some $16-18 THOUSAND dollar software apps that are only slightly better than the $5-10K apps.

Also, what’s the deal with the secret price? I had a vendor (myODPro if you must know) e-mail me a “Confidential Pricing Overview.” How lame is that?!!? Do they send me one quote and give the ECP down the street a better offer? If not, then why the secrecy?

Also, I swear it takes a full half hour just to document the exam. How can that increase my productivity? I need something faster. Maybe an EMR built specifically for tablet PC. Maybe an exam form that fits on one page. How come my paper exam fits on a single page, yet the EMR exam is separated by 4-5 tabs that I’ve got to click through? How come if I print out an EMR exam, it takes 3 pages? All forms that the software prints should be completely customizable by the user (sort of like how you can do with an MS Access database form). That way I can arrange in my preferred format the exam contents and save paper by putting it all on 1-2 pages max.

Also, how come it has to be MS Word? Why not be compatible with openoffice.org or even WordPerfect. Dell has been selling the less expensive WP a lot, and OOo is free. (Something I like after having to spend $10K+ on PMS/EMR.)

Any help?

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Josh Young, MD is an ophthalmologist out on the bleeding edge. He has a podcast featuring interviews of experts in the ophthalmic community. (His podcast even includes cool segway music.) Visit his site, As Seen From Here, and subscribe to his podcasts. He even has a great tutorial for podcasting newbies on how to automatically receive his podcasts.
As a student extern, I used to listen to Audio Archives of Ophthalmology that the office owned. When I left that rotation, I no longer had access to this since the tapes are expensive to get. Now I can resume listening to the latest pertinent topics in eye care with Dr. Young’s free podcast. Very nice.
Sure, I don’t have a long commute to work anymore (the hospital boarders my back yard), but at least I can listen while doing laundry, cleaning, etc.
The best part is Dr. Young has a phone number you can call to ask questions, so you can be on his podcast!

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In my original review of the Sonogage Corneo-Gage Plus 1AS, I neglected to mention one of my pet peeves. First, please look at this picture closely.

It shows an unwound cord while the probe wrests on 2 black, plastic deals. It is very tedious to manually unwind the cord.

Vacuum cleaner companies long ago invented a way for cords to be quickly unwound by turning a knob that allows the cord to be released. Please, Sonogage, follow their example and put a turny-knob-thingy on one of the deals that holds the probe so I can quickly release the cord. The more I use this thing, the more I hate spending the extra 3 seconds to unwind the cord.

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What is a web bulletin board, and why should optometrists care? Well, the problem lies in the very asking of this question. Doctors, as a whole, are slow adaptors to new technology. Webopedia has a short definition of a web board. They go by many different names: forum, web board, bulletin board, conference board, discussion group, and online community. I like the term forum since it’s short, but I also use bulletin board, but others prefer online community because it captures the environment they want to foster.
For those of us optometrists enlightened enough to join an “online community” or “bulletin board” with other optometrists, there is a surprising variety of choices. I will try to elucidate the features and foibles of these forums. They are in no particular order:

Seniordoc.org
A private (or moderated registration) forum for the optometric community only. Features: lots of knowledgeable, educated posters. Five post minimum for custom avatar. Drawbacks: can only register using your real first and last name (they argue that you can make an anonymous post, but still, where is the fun of having a cool username?) They have one forum viewable by the general public and then 10 forums viewable only by registered users. I argue that this gives the general public the impression that ECPs have something to hide. They don’t offer RSS feeds of new posts because, hey, that would mean Jon and Jane Public could see what we’re writing about them. On the same token, I’m sort of glad that you have to register to view posts because my real name is attached to my rantings, so I don’t want any of my patients to read something I wrote and realize, “Hey, he’s talking about me!”
Your view of that situation depends upon your goals, I guess. It’s a mess. At least you get a custom avatar relatively quick. My quick take of the community: overall good but one of the administrators is snooty and posts waaaaay to often. Seriously, if he’s got that many opinions, he should have a blog instead of monopolizing board space.

Optiboard.com
This is an open forum sponsored by opticians, but optometrists are welcome. Features: open registration. Can use any user name you want. Biggest advantage: RSS (Really Simple Syndication a.k.a “feeds”) of optiboard posts. This is huge. Now I don’t have to click through their website to read new posts. They just show up in my favorite feed aggregator (like bloglines) and then I can reply to any that interest me. This way you can lurk without having to actually click through the website. Drawbacks: mostly dispensary oriented discussions (which can be good depending on your goals). Biggest drawback is that you have to post a million times before you can get your own custom avatar. This seriously ticks me off. I tried to just post a bunch of bogus messages, but the administrator just deleted them. I had a PM (private message) with him, and he was cool, but the policy is not. An avatar represents you. It’s part of your identity. I think you should be allowed to have a custom avatar from the get-go. My quick take of the community: really friendly people.

forum.ihs.gov/~optometry
I have to admit that I moderate this forum, but I think I can be detached enough to limit my bias. Advantages: open registration with any username (but need any valid e-mail address). Get inside look at IHS optometry. Option to receive and post messages via e-mail. Disadvantages: right now it’s just starting up, so not very many users. (By the way, anyone can join in, not just IHS optometrists. I would encourage any OD2B to login and ask questions about IHS as a potential career option.) Big drawbacks are no avatars at all, and the user interface is confusing because it’s not like most web bulletin boards out there (attention IHS IT people: could we please switch to phpbb? It is practically the standard for community forums.) No RSS. My quick take of the community: so far just banter between 2 or 3 ODs. Needs more members to get it going.

visioncareforums.com
This community is sponsored by an ECP publisher. Pros: custom avatar, custom username. Cons: forums are organized by the different magazines instead of topics, so a topic could overlap from one forum (magazine) to another. Watch out for “forum spam.” No RSS. What’s weird about this forum is that it says there are a ton of topics in a forum, but when you click on it, there’s only a handful. My quick take of the community: navigation and forum organization too confusing to even get a sense of the community spirit.

EyeOrbit
There is a fine line between group blogs and a forum. I believe this ophthalmology group blog is more like a bulletin board. Anyone can register to post stuff, so I don’t see the difference. They also offer an ophthalmology resident forum. My only complaint is that it gets a little old when every other post is complaining about optometrists doing YAG capsulotomies and stuff. A big plus is that the eyeorbit blog/forum offers an RSS feed. [--EDIT-- I had originally inculed the RSS link, but it's an "rdf" file which iPodder picks up as an enclosure and tries to play in my music player. Is there anyone at eyeorbit.org that would be willing to change the file extention for their feeds to .atom or .php?]

So these are the 5 ECP-related forums that I’ve found. Which should you join? All of them, of course! Actually, web boards can take up a lot of time, so I can see how you may want to limit how many you join. I would join any eye-related forum that offers RSS feeds so that it would take minimal effort to post only to threads I care about instead of endlessly browsing topics every few days. Seniordoc really irks me because of their mandatary real-name-user-name, but Optiboard vexes me because of the mandatory 50 posts before obtaining a custom avatar. (Even though the IHS forum doesn’t have avatars period, it doesn’t bother me as much as Optiboard’s policy because it’s like they’re saying, “Look at this generic avatar! It belongs to a no-good, rotten newbie.”) Visioncareforums is just plain disorganized (which wouldn’t be so bad if they had RSS for new posts). IHS optometry web board is just starting and needs more members to create a sense of community, and it needs to drop its current software and switch to phpbb.

A community forum’s spirit is largely dependant on the users, but the forum organization and the moderators have a large role in creating that spirit. For examples of highly successful forums not related to eye care, see ericdsnider.com or wordpress.org.
Any other forums I should have mentioned?

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