Here are the steps as I see them:

1. Go to college and major in any field you want. You will be required to take prerequisite courses before entering optometry school, and most of these courses are taken during a biology-type major. But, you can major in statistics or Spanish, but it will take extra time to graduate AND get all the optometry school prereqs. Don’t let that put you off because if you don’t get into optometry school, you will want a degree that you can use to do something you love. About the only thing you can do with a biology degree besides work for the federal government is work at McDonalds.
2. The summer after your second or third year of college, take the OAT and score well. Make sure you check the option to have your scores released to all the optometry schools that you are considering.
3. As part of your optometry school application, you have to observe a few optometrists in different practice settings (private, government, research/academic, commercial) for around 30 hours. This takes time, so schedule ahead before your application becomes due. It’s also very important because you may discover that being an optometrist is not for you. That’s a good lesson to learn before you spend huge amounts of money becoming one.
4. If you still want to be an optometrist, get your application together and send it in when your fourth year of college starts. There are usually essay questions and a personal statement. Try not to write anything naive. You’ll also need to round up all your official college transcripts. Hopefully you are a fine human being and have cultivated outstanding personal, academic, and work references. I threw in a clergy reference as well. Each optometry school might have a slightly difference process, so please read their website like the careful, well-educated person you are.
5. Interested schools will call you up and schedule an interview usually starting around January. You will have to pay your own travel, food, and accomodations, so if you get a lot of interview requests, you may want to prioritize them if you don’t have unlimited funds and time. By the way, do well at the interview.
6. Wait for all the offers to pile in, and accept the one you want. I would pray about it. It’s a big decision.
7. Spend big money to attend optometry school and pay attention because there is a test later. Spend some more money on your own optometry equipment and reference books.
8. Work with a professor that you respect to plan, execute, and write a thesis project during your second year of optometry school.
9. Pay your money to take the NBEO 3-part testing and do well.
10. During your fourth year of optometry school, you will travel around to different preceptorship sites. You can focus on the type of settings you would like to work in, or better yet, experience several different settings to give you more experience if your preferred setting doesn’t work out right out of school.
11. If interested in specializing, you can do an optional optometry residency. During your fourth year you will apply and then be invited to interview for residencies. They are preferred for several modes of practice like government, academia, and LASIK centers. You’ll learn more about this and be able to make an informed decision after being in optometry school.
12. Graduate from optometry school
13. Apply for optometry licenses in the state(s) you wish to practice in.

Congrats, you would then be a practicing optometrist. For those of you counting at home, that was a minimum eight years of your life after graduating high school. I wish you luck in your quest to find a job and be happy with your career.

Before you can start working, you will need spend money on a license, malpractice insurance, perhaps a DEA number, and apply for all the insurance panels you want to take. If you decide to work for yourself instead of someone else, you’ll need to take care of a whole bunch of business related stuff that is beyond the scope of this post.

Don’t forget you will need to spend a whole bunch of money every year in the racket known as continuing education conventions.

Today I hear about an optometrist in Utah who bilked Medicaid for patients he never even saw!

Before insurance companies (especially government ones) start bearing down on all of us with burdensome regulations because of a few bad actors, let’s take a step back an look at the problem from a different angle.

This is why insurances shouldn’t pay for physician office visits, but if they want to, then leave the doctor out of it and just reimburse the patient. My car insurance doesn’t pay for oil changes or gasoline. If my car insurance was crazy enough to offer an oil change benefit, then that would be great, but if I’m Convenience Lube, then no way would I take deferred payment from some car insurance company. I would demand the car owner pay at the time of service, and their crazy insurance company can reimburse the car owner later. If my car is in a major accident, then I would less likely have cash on hand for an expensive repair, so this is when the insurance companies would step in. Besides, autobody shops are much more accustomed to dealing with insurance compared to oil change shops or gas stations.

This is how it should be in healthcare. Only certain providers would really have a need to regularly bill insurances. Mostly doctors doing surgeries, hospitals, or other high cost care environments.

Number one, this helps lower the cost of medical care because people find out how much it actually costs since doctors don’t have a big menu/price sign over the reception desk. Second, doctors don’t have to spend tons of money and time filing claims. Third, the incidence of doctors perpetrating insurance fraud would go down because doctors would have less opportunity anyway. Fourth, if something isn’t covered by insurance, who presently gets to eat it? Usually the doctor. Patients paying their own office visits would force the patient to be more accountable for whether they really want/need a particular service, regardless if they expect their insurance to reimburse or not.

The doctor shouldn’t be beholden to any insurance company. He should deliver care according to his training/experience. She shouldn’t have to try to remember that Insurance A will pay for a visual field once a year, but Insurance B will allow it twice a year, etc. He shouldn’t think about if he has the patient do an extended medical history, he can upgrade his exam from level 3 to level 4 to bilk the insurance company for all they’re worth because hey, the patient is only paying a copay, right?

I think big ticket items like billing for surgeries or expensive procedures should still be billed by providers/hospitals since this is what insurance is for: paying for catastrophic, unexpected events. But all the little stuff, like inpatient food service and routine exams and regular office visits should be paid up front by patients. It would lower healthcare costs because providers could lower prices since their labor and accounts receivable would decrease. It would decrease over-utilization since patients have a financial stake in the process. It would decrease fraud since there would be less opportunity to create fraud by the majority of doctors/patient encounters.

The procedure code is inconsistent with the provider type/specialty (taxonomy).

So I called Utah Medicaid, and confirmed that 92025 is the code for corneal topography, and they confirmed that optometrists are not allowed to be paid for corneal topography because only physicians and hospitals are allowed to bill this procedure code. I pressed that optometrists manage conditions like keratoconus with corneal topography and that their policy definitely needs to be changed. The UT medicaid worker said she would bring it up at their meeting, but that meeting isn’t until next week, and she had several other issues that weren’t address at the last meeting.

So, I think she was telling me that she couldn’t guarantee that anything regarding my issue would be addressed in the near future. Even if they do discuss it sometime this month, they might not change their mind.

THIS IS COMPLETELY RIDICULOUS!!!. Hospitals? Hospitals can bill for corneal topography? How often do they do that? Can we name even one hospital that even owns a corneal topographer? The only physicians who use corneal topographers are ophthalmologists, but if I were a pediatrician they would allow me to bill for it?

Attention Utah Medicaid Taxonomy-Procedure-Provider-Type Committee: I hereby declare that you should immediately allow optometrists, provider type 31, to bill and be reimbursed for computerized cornea topography, CPT code 92025. Blue Cross allows it. I am trained to perform and analyze this test in optometry school. I need it to manage conditions like keratoconus, irregular astigmatism, pterygium, pellucid marginal degeneration, and transplanted cornea. All of these conditions I see in my practice.

Until now, I am willing to grant that the taxonomy/provider-type thing is an oversight- a snafu with the computer database. Now that this error has come to light, the only reason I can think that Utah Medicaid would continue in this erroneous policy is that the committee members making that decision are a bunch of anti-optometrist bigots. I don’t want to think that, so please reverse your policy as quickly as possible and allow optometrists to bill corneal topography.

When people ask me what’s the difference between an ophthalmologist and an optometrist, I always like to say, “Optometrists do everything an ophthalmologist does except surgeries.”  (By the way, I don’t consider foreign body removal a surgery. Chalazion removal- yes, definitely a surgery.)  Even one of the ophthalmologists in the feature story seems to agree with that statement:

“We draw the philosophical line in the sand with surgery,” says Dr. David Parke, chief executive officer of the American Academy of Ophthalmology.

Of course, proponents of the bill think that allowing ODs to perform laser surgeries is good for people because, as Governor Beshear explains:

“I signed Senate Bill 110 to give Kentuckians greater access to necessary eye care.”

Now, I would probably refute that it gives people, particularly rural people, greater access to eye care. For a doctor to buy all the necessary equipment to perform a YAG capsulotomy, he would need to invest in a pretty expensive piece of equipment. To keep up payments, he would have to do a lot of procedures. How many YAGs does a rural optometrist usually see a month? Probably not a lot. How far away is the surgeon who did the patient’s cataract surgery in the first place? Probably not that far.

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Anyway, I kind of like my definition of optometrist. What do you all think?

H/T to Dr. Maino.

Fly open. Zipper Broken.
Eyes elevated. Me Mortified.
Seventeen bucks at Division 1 saves the day.

True story, BTW.

Beginning April 15, 2010, PEHP will no longer reimburse consultation codes. Providers will need to bill the appropriate Evaluation and Management code for the visit.

I’ve probably never had to bill a consultation code, but I imagine ophthalmologists won’t be too happy with this change.

I wonder how long it will be until every insurance company finds out that private pay individuals rarely get billed the higher fee consultation codes…

Rush brings up an ABC John Stossel report about Dr. Robert Berry who stopped accepting insurance, including Medicare and Medicaid. His office visits are as low as $40, yet his salary is typical of a primary care physician.

Well, I wish Rush would have also shared what hundreds of Wal-Mart optometrists do. We deliver eyecare for a fraction of the private practice fees. Private eyecare practices in my market of Cache Valley, Utah offer routine eye exams from $70-125. My Wal-Mart practice offers the same routine eye exam for $45-55.

Insurance companies have created this health care conundrum. Employers or individuals who buy into vision insurance are really getting scammed. My $45 exam is about what most vision insurances pay doctors anyway. So…why give any money to the middle man? And then there are a couple snobby vision plans that only let private practice doctors on their panels. The beneficiaries of these plans get doubly ripped off because sure, the exam might be covered, but when they want premium coatings or progressive lenses, they get stuck paying the balance over the basic lens. At private practice opticals, this balance can be more than the total price they might pay at Wal-Mart. So again, what good is paying money into this vision plan?

Buying vision insurance makes about as much sense as buying oil change insurance or hair cut insurance. The only people that win are the insurance companies, unless you got the coverage at no cost to you and can use your plan at Wal-Mart so that even if you do have to pay over a balance, at least you will get the best price.

In my former private practice my wholesale cost for lenses were just barely under the retail price of Wal-Mart lenses. As a doctor concerned about the welfare of my patients, I can’t continue to sell overly expensive products when Wal-Mart sells the equivalent premium products 30-50% less than what I could in my own optical shop.

So Rush, please add to your list of professionals doing what they can to control rising health care costs the excellent professionals at Wal-Mart Vision Centers.

Wow, makes me want to not take any insurance; however, I DO think that we can e-mail our patients as long as HIPAA rules are maintained. It’s my understanding that as long as the data is encrypted, we can communicate confidential information with patients. On my practice website, patients can e-mail me using a form. This form can be optionally encrypted before sending if they have confidential information to share.

This is all done using my public key. Only my private key with its password can decrypt the message. I didn’t go to the HIPAA Security Company store and buy it. It’s totally free if you know how. While I believe this system complies with the intent of HIPAA regulations, I can’t e-mail back a patient if they haven’t made themselves a cryptographic key pair for e-mail. I’ll bet only a very small percentage of people in the world even have one, and I’ll bet the percentage of doctors that have encrypted e-mail is even less than the general population. But I did it. It’s do-able. Sure, I’m a computer geek, but I learned computers the same way I learned eye doctoring; study and practice.

But the obscurity/confusion of how to implement encrypted e-mail communications is not the real reason doctors don’t use it. I don’t get paid to sit around and e-mail patients. I get paid for examining patients at the office. On-line communication tools work well for Dr. Parkinson since that is his mode of practice. But my patients don’t pay me a subscription, so any e-mail that I have with them would most likely say something like, “I would recommend you come in for an appointment.”

By the way, I’ve had this encrypted form feature on my website for over 18 months, and no one has ever used it nor have they used my public key to send me an encrypted e-mail.