Eye exams

Issue: BCMJ, Vol. 48, No. 5, June 2006, page(s) 210 Letters
Ari Giligson, MD

I am writing with hopes of acquainting the family practice community with a problem that some of our older, poorer patients are having with eye examinations.

A patient in her mid-seventies was recently sent to see me for a diabetic eye check. I had last seen her about 4 years earlier and asked who had been checking on her in the interim. She told me that her primary physician had asked that she see a local optometrist for her eye checks. (“After all, he can do everything that the ophthalmologist can for you.”)

Everything and more it would seem.

The reason for her decision to see me again was that she could no longer afford to see the optometrist. Some of our primary physician colleagues may not be aware that it is the policy of many optometrists to “balance bill.” That is, they charge the province the going rate for seeing a patient and then bill the patient the rest to add up to the “actual” charge. And there are also charges for diagnostic tests outside the realm of those deemed medically necessary.

In most circumstances, physicians are barred from balance billing; optometrists are not. My patient could no longer afford the charges for her visits (in my mind, too frequent) and for her associated diagnostic tests (in my opinion, not indicated). We agreed that she would see me on an annual basis for her diabetic checks.

The moral of the story is be aware of the costs incurred by patients when sending them for disease-associated eye screening by optometrists and beware of the nature and strength of a fiduciary relationship vis-à-vis optometrists vs ophthalmologists.

—Ari Giligson, MD

The BCMA responds

Thank you for your letter regarding family physician referral of low-income elderly patients to optometrists who “balance bill” patients for eye examinations and other optometric examinations. Your concern for patients who cannot afford to pay for these services is understandable. However, any eye examination services that you bill to MSP must meet the criteria for eye examinations by an ophthalmologist in accordance with the current guidelines.

According to the MSP guidelines, an eye examination is an insured benefit if it is medically required and meets the criteria for referral: “It is the responsibility of General Practitioners to exercise their judgement in referring those patients for whom an eye examination is medically required… Formal referrals to ophthalmologists or direct requests to optometrists for an eye examination on behalf of patients are appropriate only if, in the practitioner’s judgement and based on clinical evidence, there is medical necessity for the examination. Refractive change (needing glasses or contact lenses) with no other pathology does not meet the MSP medically required criteria for payment.”[1]

A medically required examination by an ophthalmologist (fee item 02015) is an insured benefit if the diagnosis meets the MSP definition of “medically required” in accordance with the ICD9 codes listed in the guidelines. A complete list of conditions and associated billing frequencies is included in the “Changes to Eye Examination Benefits” guidelines. To ensure that you are billing in accordance with the approved criteria, consult the current guidelines which can be found on MSP’s web site at www.hlth.gov.bc.ca/msp/infoprac/index.html (click on the link for “Eye Exams”), or call the BC Medical Association at 604 736-5551. We will be happy to provide you with a copy of the guidelines and any other assistance you might require.

Should you feel that it is in your patients’ best interests to see you rather than an optometrist, it would be appropriate for you to provide a service for any medically required condition, providing the MSP criteria is met.

—Julianne Officer, Fee Schedule Manager, BCMA

References Top

1. Medical Services Plan of BC. MSP for Medical and Health Care Practitioners. www.hlth.gov.bc.ca/msp/infoprac/eye_exam.pdf (accessed 12 May 2006).