Alot has been written about how you can hold your ground — and even advance — by adding ancillary services to your fee-starved Medicare revenue stream. What hasn’t been written about, though, is how much doctors are charging for these services. Governed by anti-trust law, ophthalmologists are generally close-mouthed about fees. Although understandable, the silence creates an information void that we’d like to help fill.

In a confidential, informal survey, we asked 20 randomly selected ophthalmologists from across the country how much they officially charged for ancillary services, despite what Medicare or insurers paid. Then, we asked experts in each category to comment on the results.

We began our survey by asking respondents how much they charge, on average, for an exam and consultation leading to aesthetic laser surgery. Five physicians responded with fees ranging from $0 to $150. The average charge was $55.83

Brenda Ropoulos, former medical communications manager at Coherent Medical, called the range of consultation fees "reasonable." She pointed out that many doctors apply some of their consultation fees toward the price of the surgery.

The average charge reported by five ophthalmologists for aesthetic laser surgery on the eyelids and surrounding tissue was $1,450, with fees ranging from $750 to $2,000.

Four physicians reported an average fee of $3,050 for aesthetic surgery on the full face, while aesthetic surgery on the face and neck brought in an average charge of $3,766 among three physicians.

For medically indicated blepharoplasty, eight doctors reported an average fee of $1,507. Responses ranged from $530 to $3,000.

Cosmetically indicated blepharoplasty brought in a slightly higher result, with eight physicians reporting an average fee of $1,800. Charges ranged from $625 per lid to $2,200 for lower lids. Ms. Ropoulos thought the average fee was appropriate, but considered the $625 fee to be too low.

Not surprisingly, none of our respondents reported fees for facial hair removal. According to Ms. Ropoulos, "Even though hair removal is a very simple and quick procedure, ophthalmologists have been slow to do it because it requires a marketing effort."

Commenting on the overall results for aesthetic surgery, Michael E. Migliori, M.D., of Providence, R.I., called the fees "about average. The range of fees across the country is as wide as the sample you have," he said.

Dr. Migliori pointed out that factors affecting aesthetic surgery fees include the cost of supplies, technicians and laser fees (if done in the office). "Also, surgeons with outstanding reputations can often command higher fees than others in their communities," he added.

We asked respondents how much they charged, on average, for an exam and contact lens fitting, including fees and materials, for a variety of lens designs. The average fee reported for each lens design (the number of respondents is indicated in parentheses) appears below.

• soft spherical lenses: $170 (13)
• soft multifocals: $234 (8)
• soft torics: $238 (11)
• soft tints: $201 (9)
• rigid gas permeable (RGP) spheres: $208 (10)
• RGP multifocals: $279 (9)
• RGP torics: $238 (7)

Interestingly, Robert Cykiert, M.D., F.A.C.S., of New York, N.Y., says he believes that the average fees reported for soft spherical, soft multifocal and soft toric contact lenses "undervalue the skill, time and expertise" needed to fit these lenses.

He found the same to be true of the findings for RGP sphere and multifocal lenses, saying that $300 would be more of a fair value for RGP spheres and that $400 would be more appropriate for RGP multifocals.

Of the RGP torics, he said, "these should be priced similarly or higher than multifocals."

The only charge Dr. Cykiert didn’t dispute was the average fee for soft tints, which was $201. "This charge is about right because these lenses are similar to spherical lenses, but color customized," he said.

Warren McDonald, Ph.D., F.N.A.O., director of Contact Lens Services at the Jacksonville Eye Clinic in Jacksonville, N.C., generally agreed with Dr. Cykiert’s findings. "The trend I see is that doctors are undercharging for specialty lenses, like multifocals. These are highly specialized designs that take a considerable amount of expertise to fit."

Dr. McDonald advises doctors not to undervalue their professional fees. "Not everyone can fit a specialty lens, so charge appropriately for your services," he said.

Indicating, perhaps, that doctors may be underestimating their services by an even greater margin, six of nine respondents told us that they include follow-up visits in their initial fitting and exam fees. The remaining three respondents reported follow-up fees ranging from $43 to $100.

Dr. McDonald calls follow-up visits "difficult to get a handle on. In my area, they’re generally included in a global fee structure and include a 6-month follow-up. I see nothing wrong with a charge for chair time after a few months.

"The $100 fee may be a bit much," Dr. McDonald continued, "but if it hasn’t adversely affected the practice, then I’d say it’s okay."

To determine a fair market value for follow-up visits, Dr. McDonald recommends that doctors watch their markets. "If you try to go against the market you might deter a potential patient. But a $15 fee wouldn’t deter anyone."

For an exam and consultation leading to punctal occlusion, our survey results indicated an average charge of $96 among 14 doctors. Results ranged from $50 to $150.

For permanent punctal occlusion with silicone punctal plugs for two punctas, 12 doctors weighed in with an average fee of $237. Ten doctors reported an average of $482 for permanent punctal occlusion with punctal plugs for four puncta.

For cauterizing puncta, the average charge among 11 doctors for two puncta was $293. Ten doctors reported an average fee of $517 for cauterizing four puncta.

Riva Lee Asbell, principal of Riva Lee Asbell Associates, an ophthalmologic consulting firm in Philadelphia Pa., says that there’s a great deal of misinformation regarding billing patients for punctal occlusion.

"Medicare patients cannot be billed for these services because they’re covered services," she explained.

"If the services are not covered by other insurers, there’s a possibility that the patient can be billed, but that would depend on the provider agreement," she added.

According to Ms. Asbell, Medicare fees for CPT Code 68761 (punctal occlusion by plug, each) range from $95.47 in Arkansas to $100.41 in North Carolina to $113.36 in Pennsylvania.

Medicare fees for CPT Code 68760 (closure of the lacrimal punctum by thermocauterization, ligation or laser surgery) range from $118.71 in Arkansas to $124.75 in North Carolina to $140.51 in Pennsylvania.

The average gross optical sale among eight ophthalmologists was $194. Arthur De Gennaro, president of Arthur De Gennaro & Associates, LLC, a practice management consulting firm specializing in dispensary profitability, says the average should be closer to $250, primarily because M.D.s sell so many pairs of bifocals. "I have clients with average sales well over $300, and I’ve worked with some that started as low as $170, with very little managed care," he said.

Mr. De Gennaro pointed out that fluctuations in average unit sale can come from a variety of sources. Among them:

• a high percentage of highly discounted orders, mostly due to managed care
• counting one lens only and lenses-only sales in the computation
• poor selling effort
• incorrect retail pricing (not marking frames and lenses up high enough)
• poor positioning — incorrect market niche
• inappropriate merchandise mix for the practice’s market segment
• not keeping good business records, which leads to "guesstimates" and errors.

We also asked respondents how much they charged on average for the following lenses (the average fee is followed by the number of respondents in parentheses):

• progressive addition lenses: $151 (3)
• bifocals: $92 (2)
• trifocals: $105 (2)
• polycarbonate or plastic lenses: $55 (3)
• high-index lenses: $73 (2)
• aspheric lenses: $60 (1)

The average charge for a refraction among 16 ophthalmologists was $28.

For lens treatments, such as anti-reflective coating, tinting and scratch coating, five doctors reported average fees that ranged from $13 to $48.

For prescription sunglasses, two doctors reported an average charge of $228. For plano sunglasses, three doctors reported an average of $91 with responses ranging from $45 to $140.

While our survey was by no means scientific, our results indicated that ophthalmologists appear to be undervaluing optical and contact lens services. If ancillary services will have a future role in your practice, it might be wise to heed the advice of Dr. McDonald and "watch your market."

Maybe a word about fees now and then isn’t such a bad idea after all.