Preventing Patient Conflict

Avoiding “Sticky Situations” in Contact Lens Practice

Suggested methods for handling five common complaints that create discord with patients.

By Brian Chou, OD, FAAO, & Kelvin Nguyen, OD

Drs. Chou and Nguyen are partners at EyeLux Optometry, one of the largest private contact lens practices in San Diego. In 2000, Dr. Chou completed a fellowship in the Cornea and External Disease Division of Jules Stein Eye Institute, UCLA School of Medicine. He has served as a consultant to Transitions Optical and Tigris Ventures, LLC. Dr. Nguyen previously owned and operated two practices in Merced, Calif., before moving to San Diego in 2006.

In a perfect world, contact lens practitioners can do what is best for patients without worrying about price objections or non-adherence. Yet those of us in day-to-day clinical care know that in reality, this is hardly the case. Patients do not always understand nor value what we do for them, and increasingly, they seem to question whether our actions are motivated by self-interest. In the worst cases of misunderstanding, tempers can boil over leaving patients and practitioners fuming, with collateral damage to your practice.

Below are five “sticky situations” that can occur in contact lens practice. For each, we have included our strategies to avoid them.

The Situations…

STICKY SITUATION #1: A patient complains that the “contact tens fitting fee” is unjustified because the contact tens prescription is the same as before.

The following online review from Yelp.com for an optometric practice (identity not revealed) exemplifies this issue: “My problem is with the ‘contact lens fitting fee.’ I have had the same prescription for five years. I do not understand why I must pay for this fee every time…this fee irks me and seems a little shady.” A sampling of negative online reviews for contact lens services reveals that a surprisingly large number share this same theme.

The Great Recession has led consumers to scrutinize what they are paying for. Indeed, we all encounter questionable fees in our everyday lives with utility services, travel expenses, or banking transactions. To unenlightened patients, the “contact lens fitting fee” may seem like a “garbage” fee.

The “contact lens fitting fee” has become more conspicuous to patients since the Dec. 6, 2003 enactment of the Fairness to Contact Lens Consumers Act (FCLCA) and the concurrent rise of contact lens fulfillment through online and big box retailers. Prior to the FCLCA and the growth of alternative contact lens fulfillment, many practitioners did not charge separately for contact lens services. Rather, these practitioners had shifted the cost of their service into the price of their contact lenses, and thus it was hidden. Yet today, most contact lens practices charge for professional services in order to price their lenses competitively with online and big box retailers.

For many patients, the enduring reminder of receiving contact lens services is their supply of contact lenses. If a patient walks in with a specific contact lens, then walks out with the same lens prescription, the patient may wonder whether services were even performed. To a layperson, the term “fitting” is commonly associated with clothing and accessories. Average consumers can fit themselves for these items, and it is within the same context that they believe a contact lens is “fit.” Why should they pay for something that they believe they can do themselves, particularly if they end up with the exact same contact lens? It is somewhat unfortunate that our industry has chosen to embrace the term “fitting” because this does not appropriately portray the rendered service. Alas, it may be too late to change the terminology, because it is ingrained within our field. Still, you can increase patient understanding by replacing “contact lens fitting” with “contact lens evaluation” or “contact lens prescribing” to accurately portray the service being performed.

A contact lens evaluation involves case history, examining the physical relationship of the lens to the ocular surface, the health of the ocular surface, the condition of the contact lens (e.g. deposits, defects), and performing over-refraction. The practitioner evaluates for the prospect of enhancing the patient’s wearing experience by improving health, comfort, vision, or convenience of wear, and saving the patient money, by prescribing an alternate lens. This evaluation requires additional chair time above and beyond what is needed for non-lens wearers, and hence carries its own separate fee.

Contact lens prescribing involves creating a valid contact lens prescription, whether new or modifying a previous prescription. The time and complexity related to creating the valid prescription should form the basis of assessing fees for your service. Many practitioners (including us) have found it helpful to establish several levels of elective contact lens prescribing services to pattern the Evaluation and Management codes (99XXX). In this model, the lowest level contact lens service is merely the evaluation, which may involve duplicating the existing prescription, if appropriate. The service levels then escalate to simple contact lens prescribing (spherical frequent replacement) up to the highest level of complexity (bitoric GP contact lenses and presbyopic prescribing). The fees should increase in lock-step according to the amount of chair time and administrative time for ordering diagnostic lenses and performing any lens exchanges. There should be separate fee schedules for corneal reshaping and medically necessary contact lens prescribing (e.g., keratoconus, post-surgical, and post-trauma eyes).

Apart from these measures, make sure that patients are aware that a valid contact lens prescription involves services with corresponding fees that are outside of the realm of a general eye examination. This can be conveyed at several touch points, including at the time of appointment scheduling, through the practice website, and at completion of registration papers. In essence, both new and established patients should opt-in to have a valid contact lens prescription that they can fill during the course of the year. The concept is to make transparent that contact lens services are required and desirable, and above-and-beyond what is performed during a general eye examination. For quoting cost, your staff can provide your range of contact lens service fees, with the minimum fee corresponding to a contact lens evaluation.

When changing a patient into a different spherical frequent replacement lens, it is often valuable to explain to the patient that even if the power of the contact lens remains the same, the prescription is different. Most consumers do not recognize that lens power and lens prescription are not synonymous with one another. They need to know that a contact lens prescription encompasses parameters including material, base curve, diameter, and power.

Finally, it is helpful for practitioners to explicitly state when they are performing contact lens services during the examination. For example, you can explain what you are doing during over-refraction and during the slit lamp evaluation of the contact lens and anterior segment. It can be as simple as stating, “The contact lenses appear safe on your eyes and should not pre-dispose you to abrasion, redness, or infection.” Otherwise, the patient may not even recognize that you are spending additional chair time. You can also build value by letting patients know that when iterations and exchanges are needed, the new lenses are related services within a stipulated time period and are included within the global service fee.

STICKY SITUATION #2: A patient alleges that the soft frequent replacement contact lenses that you prescribed are not performing well and tries to return opened revenue boxes four months later.

If physicians prescribe systemic antibiotics but patients experience an unexpected sensitivity or allergy to the medicine, patients would still absorb any out-of-pocket expenses for the medicine. Yet due to the commoditized nature of the frequent replacement contact lens market, the analogous situation—in which a soft contact lens fails to perform according to patients’ expectations—will lead some patients to try to return their contact lenses, as if they were an article of undesired clothing.

Practitioners can proactively minimize these situations by explaining at the time of prescribing a different contact lens that their intent is to improve ocular health, vision, comfort, and convenience as well as to reduce cost, or a combination of these factors. Yet due to individual response, there are instances in which patients may unexpectedly prefer their habitual contact lens. While patients should know that they can fill the contact lens prescription thereafter, they should confirm for themselves that the diagnostic lenses are performing to their liking before opening up the revenue boxes, which renders them invalid for exchange or return.

In the event that patients do not wish to fill the new prescription, they should call the practitioner to indicate their preference to return to their habitual contact lens type. This can be completed without consuming an examination appointment. Still, if practitioners change patients simply from one spherical lens to another, there should be a sufficient fee assessed to cover the possibility of an unexpected progress visit or patient communication. In the unusual event that patients dislike the new contact lens prescription, they should still appreciate the opportunity to wear a new, advanced lens technology.

Patients’ walk-out statements can indicate a practice’s policy for contact lens exchanges, returns, or refunds. For example, the statement can reference the webpage on the practice’s website that has the ophthalmic product policy. The warranty should cover a period of time that represents the least amount of warranty period of all your contact lens vendors for exchange. For example, if one laboratory offers lens exchanges within a 60-day period, and another laboratory that you use offers a warranty of 90 days, your ophthalmic product policy should state a 60-day warranty period for simplicity’s sake. It is best to under-promise and over-deliver, as you can always break your own rules in favor of patients when needed. Also bear in mind that your contact lens vendor representatives are sometimes willing to offset the material cost when lenses do not work out for patients. There should always be room to address issues on a case-by-case basis in the event of extenuating circumstances.

STICKY SITUATION #3: A patient wants to try every available soft frequent replacement contact lens known to mankind.

A minority of patients wish to try every available soft contact lens brand. They are the same ones who would like to try on every eyeglass frame in your optical dispensary. In psychology, these types are called “maximizers”: those who are not satisfied with good, but want only the best and will go to great lengths to examine every option even if it is actually at their own detriment. Although contact lenses are prescriptive devices, the direct-to-consumer advertising by major contact lens manufacturers makes it seem that these lenses can be “fit” in a do-it-yourself manner. It does not help that these manufacturers label the diagnostic lenses as “free,” “sample,” or “trial,” because it can encourage self-prescriptive behavior by maximizers.

In prescribing contact lenses for maximizers, it is important to establish from the start a common understanding of the process. You can certainly prescribe different contact lenses for such a patient, as long as the patient undergoes the appropriate contact lens services and pays the accompanying fee. Without making it evident that there is a cost to the patient in time and money, a maximizer may not realize that there is a point of diminishing returns—such as driving an extra mile just to save one cent per gallon of gas. Educating your staff to address these requests is invaluable in saving you time.

It is often tempting to oblige a patient’s request because of an inherent desire to satisfy the consumer. Yet your clinical expertise and practical wisdom should ultimately dictate what you prescribe. The maximizers may overlook your years of professional schooling and clinical experience, assigning more value to their desire to redeem a “free trial lens” coupon. For example, if patients are having comfort problems, in our opinion it is not logical to move them from a silicone hydrogel lens and peroxide-based care system into a polymacon material and antiquated multipurpose system. Similarly, a low myopic astigmat wearing a spherical contact lens is unlikely to obtain improved visual acuity if you acquiesce to his request to prescribe another brand of soft spherical lenses rather than a toric design.

We do not advise providing blister packs of multiple types of lenses to patients and asking them to compare different contact lens options, due to the risks of confusion and further misperceptions about the process. Additionally, practitioners have the fiduciary responsibility of using their position of superior expertise for patients’ benefit. Providing multiple blister packs of different lenses demonstrates a lack of clinical expertise, similar to handing patients several different artificial tear drops and asking them which is best, as if you have no idea. If patients must compare the new lens against another, it should generally be only against their habitual contact lenses. Any additional new contact lens comparisons are welcome with the caveat that patients know that they will incur a fee to cover administrative and professional time.

Finally, do not neglect the high likelihood that patients who perpetually complain of lens wearing discomfort may, in fact, have unmanaged ocular surface disease in the form of allergy, blepharitis, and/or dry eye. In these cases, patients need to know that any contact lens will compromise their already low threshold for comfortable wear. Otherwise, patients may go on a witch-hunt believing that some magical contact lens will cure their wearing discomfort. In these cases, your attention, as well as patients’, should go toward treating the ocular surface disease.

STICKY SITUATION #4: A patient has run out of contact lenses or has damaged or lost his last set. With no eyeglasses and his last examination almost three years ago, the patient calls and demands to get a renewed contact lens prescription without examination, citing, “I haven’t noticed any changes.”

Human nature is to procrastinate to the point of urgency. Contact lens wearers are no different, often waiting until they are on their last pair of frequent replacement contact lenses before scheduling an examination. These are opportunities for your staff to underscore the importance of buying eyeglasses, not only for situations in which they run out of lenses, but also in the unexpected event of eye infection when contact lens wear is contraindicated.

Your staff’s challenge is to effectively convey that an examination is in patients’ best interests for detecting asymptomatic changes to vision and eye health, and that it is also your duty as an eyecare practitioner to perform the examination. If no immediate appointment is available, you can authorize your staff to provide a patient who wears frequent replacement soft contact lenses with a pair of matching diagnostic lenses as a stop-gap measure provided that the patient schedules an examination and arrives wearing them for evaluation. If the exact power match to the patient’s habitual lenses is not available, it is reasonable to provide the patient with the closest power as long as this is documented, so that you know the patient’s clinical situation during the examination.

In providing a pair of diagnostic contact lenses, your staff should clearly set the expectation that this is a one-time favor to the patient. Your practice should discourage patients from waiting to the last moment when they are out of contact lenses before scheduling an examination.

For patients who are completely out of made-to-order contact lenses, you can have the previous lenses ordered on a warranted basis and then schedule their dispensing during a routine examination. With custom orders, your staff should let the patient know that there is a warranty period during which the practitioner can make any needed refinements and exchanges at no further lens cost to the patient. This should enhance the patient’s adherence in keeping the examination appointment.

STICKY SITUATION #5: A private-pay keratoconus patient wants you to prescribe GP lenses that he can order online.

It may seem absurd that a keratoconus patient would make such a request. It makes us wonder whether cardiologists have ever had patients request that they use a specific type of cardiovascular stent during their heart surgery. Yet these requests have happened within Dr. Chou’s irregular cornea practice. This patient mentality is usually associated with the commodity, direct-to-consumer advertised contact lenses, which is not entirely their fault. The prototypical consumer-driven lens is usually an iris-color-changing tinted contact lens used for cosmetic applications. By comparison, patients do not generally ask for a bifocal toric soft contact lens or a bitoric GP lens, both of which are practitioner-driven. Contact lenses for irregular corneas surely fall within that category as well.

While it may be unexpected for patients who have corneal disease to request a lens prescription that they can order online, the degree to which patients generally believe that they can do everything online is well illustrated by the hoax website, www.LASIKatHome.com. Although it is obvious to anyone in our industry that LASIK is not a do-it-yourself procedure, there are consumers who actually believe that this is a legitimate kit for purchase. The mere fact that some consumers believe this makes it understandable how others who have corneal disease might believe that you should prescribe their lenses as if they were commodity frequent replacement soft lenses.

It is critical that you educate these patients that made-to-order custom lenses require your direct communication with your GP laboratory, and that you have an existing relationship with such a facility. You can also challenge these patients to find an online GP laboratory that can fabricate proprietary lenses for keratoconus, or fulfill specified GP parameters such as optical zone, peripheral curve widths, and radii. If such a laboratory even exists, patients should be apprised that they would need to be entirely responsible for requesting and paying for each order on their own (perhaps in addition to establishing an account with such a laboratory). Most patients should realize that the high likelihood of lens exchanges with irregular cornea conditions will mean that online ordering will likely cost them more in money and time, along with greater uncertainty.

At the end of the day, irregular cornea patients need to know that it is difficult for you to provide for their optimal treatment if you do not have complete control over the quality of the prescribed lenses. These patients may also need further education to understand that they have a serious medical eye disease. An excellent resource for keratoconus patients is the National Keratoconus Foundation (www.nkcf.org).

Other Situations…

There are certainly other “sticky situations” that arise in clinical practice. The underlying principle to remember is that the patient’s perception and expectations often require modification by education. The key to preventing and resolving these situations is good communication. CLS