Retinal Photography
Out-of-pocket charges to patients for retinal photography (widefield or otherwise) and other procedures billed in the same manner.
This Board Policy was created to address an issue that has been brought to the Board’s attention multiple times recently regarding routine patient care. However, the Policy would apply any time the patient is asked to pay an out-of-pocket surcharge for a procedure such as retinal photography whether the patient is classified as routine or non-routine. This Policy is directed at ensuring patients are well informed about a practice’s policy when elective procedures are offered that require a surcharge or out-of-pocket fee.
Recently, many practices have adopted the policy of performing retinal photography in lieu of dilation of a patient for a comprehensive eye exam. This has become an acceptable alternative when a patient presents without history and/or symptoms of potential or known retinal pathology.
However, the provider should not become either too comfortable with or too dependent on this procedure and not be prepared to dilate a patient when indicated. The American Journal of Ophthalmology, November, 2023, states the following: “Nearly half of horseshoe tears were missed by UWF [Ultra Wide Field] imaging” because the majority of these occur in the superior quadrant where the UWF imaging has a limited view. A dilated retinal exam remains the standard of care for evaluating retinal pathology.
It is rare that an insurance company will cover the fee for this service when there is no associated diagnosis. Therefore, the patient is usually responsible for the out-of-pocket surcharge associated with this procedure. Often, this additional cost is acceptable to the patient in order to avoid the disadvantages of dilation. However, the Board has received several complaints from patients who object to paying this out-of-pocket fee as a condition of being seen.
The Board takes no position on whether a practice offers retinal photography, and if so, whether it does so as an optional procedure or as a required procedure so long as the optometrist is following the standard of care and patients are being appropriately informed. Patients should always have the opportunity to make informed decisions, and patients should be given that opportunity. When the patient should be informed depends on whether the practice considers the procedure to be optional or required, as explained in more detail below.
Practices offer, recommend, or require widefield retinal photography or other retinal photography procedures for a variety of reasons. Some of these are as follows:
Additional revenues for the practice.
Dilation of the pupils requires a waiting period; retinal photography decreases the patient’s exposure time in the practice. It also avoids the close working distance required in a dilated retinal exam.
Pupil dilation can impact the patient’s vision for several hours following their examination. It can also create ambulation and driving problems for the patient that can be avoided with non-dilated retinal imaging.
Permanent documentation of the patient’s retinal status.
Promoted as superior technology and better than the standard of care (such standard being a dilated retinal evaluation). However, the Board believes this statement or similar statements are not accurate, because there is no evidence-based research supporting such proposition with regard to evaluation of routine patients (as defined above).
When you are offering retinal photography or any other similar procedure with an out-of-pocket surcharge, you must decide if you are offering this procedure as an optional or required procedure. Once you have made that decision, you must adhere to the following guidelines:
Optional Procedure:
No matter whether the optometric practice simply informs the patient that the procedure is available, or whether it recommends or even highly recommends the procedure, it falls into the “optional” category because the procedure is not required. The patient must be given a clear choice of either dilation at no additional charge or photography with an additional out-of-pocket fee in lieu of dilation.
It is best that the option be presented to the patient when they book their appointment. However, it would be acceptable if the option was presented to the patient when they arrive and are being checked in for their appointment.
Making the patient aware of the option in this way avoids making the patient feel pressured or feel they are inconveniencing the provider or practice by not accepting the option or recommendation. We are aware of incidents where the patient paid the fee and then complained to the Board that they did so because they felt they were placed in an awkward situation.
Alternatively, and at the discretion of the practice and if acceptable to the patient, the fee can be waived and the retinal photography procedure performed at no cost to the patient.
Required Procedure:
Some practices have made the decision that all routine patients seen in their practice are required to have the retinal photography procedure in lieu of a dilated retinal exam–the procedure is not optional or waivable. The patient is required to pay the out-of-pocket fee if not covered by their insurance or vision plan. While many patients will gladly pay an out-of-pocket upcharge to avoid having their eyes dilated, some will object.
Practices requiring this procedure and associated fee must inform the patient while the patient is booking their appointment and before their appointment is finalized. At that time, the patient must be given the option of accepting and agreeing to this requirement or not agreeing and seeking care from a different provider. If the patient is booking their appointment online, this should be an active acknowledgement such as, the patient initialing a stand-alone statement indicating, “I understand the requirement and associated fee.” It should not be a signature on a document with multiple policies linked or attached, which has a greater tendency to be overlooked by the patient. If the patient is booking their appointment on the phone, paperwork reflecting the patient’s verbal acceptance of this requirement and fee prior to the patient reporting to their appointment is required and must be appropriately documented in the patient record. Should a patient walk-in to the practice and ask for an exam, the requirement should be conveyed to and agreed to by the patient prior to the exam beginning, with the walk-in nature of the exam noted.
If the practice has not informed the patient and the patient therefore, has not agreed to the practice’s requirement prior to presenting for their appointment and upon being so informed, the patient expresses concern about the requirement, the practice shall either waive the fee for the procedure or perform a standard dilated retinal exam. The practice should not put the patient in the uncomfortable position of either paying for a procedure they didn’t agree to prior to arriving at the practice or leaving the practice to avoid paying the fee.
In no case should patients be refused care and sent away from the practice when the patient questions or objects to the fee for any of the following reasons: the patient indicates he/she was not presented with the acknowledgement, he/she did not sign the acknowledgement, he/she did not understand the requirement if signed, or similar reasons. The practice should either do the procedure, waiving the fee one-time, or perform a dilated retinal exam. They should document the one-time waiver by having the patient sign the statement in Appendix 1 or a similar statement of acknowledgement.
Should a patient refuse to sign the statement in Appendix 1, the practice should still see and examine the patient as a one-time courtesy. However, the practice is then free to discharge the patient going forward using a standard discharge letter. (An example of this type of letter is attached in Appendix 2.)
In no case can the procedure be promoted as better than or superior to a dilated retinal examination for the reasons stated above.
Examples:
When the Procedure is offered to the Patient as OptionalOptional:
Ms. Jones, our practice offers widefield retinal photography which captures an image of the back of your eyes. With this technology, you do not have to have your eyes dilated and can avoid the bright lights needed to examine the back of your eyes. The doctor will review the image with you during your examination. The fee is $XX in addition to your regular exam fees. It is totally optional, so you can have the standard dilated exam if you choose. Would you rather have the retinal photography or have your eyes dilated?
Mr. Jones, our practice offers widefield retinal photography which captures an image of the back of your eyes. With this technology, you do not have to have your eyes dilated and can avoid the bright lights needed to examine the back of your eyes. The doctor highly recommends this procedure as he/she is able to see areas of your eyes that are harder to view in a standard examination. (However, the procedure cannot be promoted as better than a dilated examination.) The fee for this procedure is $XX in addition to your regular exam fees. However, it is not required and you can choose to have the standard dilated examination. Which procedure would you like?
When the Practice Requires the Procedure:
This conversation or online disclosure must occur when the patient is scheduling their initial appointment (or for walk-ins prior to the beginning of the examination).
Ms. Jones, our office is now performing widefield retinal photography on all of our regular examination patients. This technology captures an image of the back of your eyes as a permanent record. With this technology, you do not have to have your eyes dilated and can avoid the bright lights needed to examine the back of your eyes. There is a fee for this procedure of $XX which is in addition to your regular examination fees or insurance. If for some reason you would rather not have this procedure and instead have a standard dilated retinal examination, we understand. Since our practice is now requiring this as part of your regular examination, you would need to visit a different provider/practice. Upon request, we will be happy to transfer your records.
Mr. Smith presents for an examination and while he was told of the requirement to pay an out-of-pocket fee for UWF imaging, he does not recall the conversation or requirement and objects to the fee. The practice should respond, as a one-time courtesy, they will either waive the fee for the procedure or perform a dilated retinal exam without a fee. The practice will have the patient sign a statement acknowledging the one-time waiver so the issue does not present in the future.
Adopted 8/23/2021
Amended 12/30/2024
Amended 02/05/2025
Appendix 1:
Practice Information and Date
Because I was not aware of or didn’t understand the required out-of-pocket fee for the procedure(s) described, I understand the practice is waiving the fee as a one-time courtesy. I understand this is a required procedure and fee for future routine examinations.
_____________________________
Patient Signature
******************************************************************************
Appendix 2:
Example of a Patient Dismissal Letter:
"Dear [Patient Name],
This letter is to formally notify you that we are terminating our physician-patient relationship, effective [date 30 days from letter date]. This decision is due to [specific reason for dismissal, e.g., repeated missed appointments, non-compliance with treatment recommendations].
We encourage you to find a new healthcare provider as soon as possible. During the next 30 days, we will provide necessary emergency care, but will not be able to schedule routine appointments.
To facilitate the transfer of your medical records, please provide written authorization to your new physician to access your information.
We wish you the best in finding suitable medical care elsewhere.
Sincerely,
[Doctor's Name]"
Key points to include in a patient dismissal letter:
Clear statement of termination: Explicitly state that you are dismissing the patient as a patient.
Reason for dismissal: Clearly explain the specific reason(s) for ending the relationship, but be respectful and avoid unnecessary details.
Effective date: Specify the date when the dismissal takes effect, usually allowing a reasonable time for the patient to find a new provider.
Record release instructions: Inform the patient how to request their medical records and provide necessary forms.
Contact information: Provide contact details for any questions or concerns.
Important Considerations:
Consult legal advice: Before sending a dismissal letter, especially if the situation is complex, consult with a legal professional to ensure compliance with local regulations.
Document communication: Maintain a record of previous attempts to address the issues with the patient before dismissing them.
Professional tone: Always maintain a respectful and professional tone throughout the letter.