A practical approach to communicating patient responsibility, setting defensible fees, and maintaining financial sustainability. 

Ms. Smith is preparing for cataract surgery and is told that the procedure is covered by Medicare. During surgical counseling, however, she elects a presbyopia-correcting intraocular lens (IOL) and learns that she will owe several thousand dollars out of pocket. Her questions are predictable: “If cataract surgery is covered, what exactly am I paying for? Does this amount include the surgeon and the surgery center? Could the price change? And if the expense is difficult for me, what payment options are available?”

For ophthalmology practices, these questions illustrate why fee transparency means considerably more than publishing a fee schedule. Cataract surgery commonly combines covered medical services with noncovered services during the same episode of care. Professional and facility fees may be separate. Insurance coverage may determine some amounts while other prices are established by the practice or facility.

The challenge, therefore, is not simply price disclosure, but price comprehension. A patient who receives a price without understanding what it includes has been given information without necessarily being informed. Research on cost-of-care communication suggests that patients benefit from clear team roles, reliable cost information, and estimates of expected out-of-pocket expense before treatment begins.^1-3 This leads to a useful concept: informed financial consent. Just as clinical informed consent requires more than obtaining a signature, meaningful financial consent requires sufficient understanding to make an informed decision before treatment.⁴

What Should Patients Know?

The first challenge is terminology. A charge is not necessarily the amount an insurer allows, the amount the insurer pays, or the amount the patient ultimately owes. Patient responsibility may include a deductible, copayment, coinsurance, or payment for a service excluded from coverage. Further, professional and facility fees may be billed separately.⁵

Patients do not need a lesson in reimbursement methodology, but they do need understandable answers to several questions: “What am I paying for? Why am I responsible for it? Is insurance expected to pay any portion? Who else may bill me? Is the amount fixed or estimated?”

Cataract surgery provides a useful example. Medicare covers cataract extraction with a conventional IOL. A beneficiary may instead select certain presbyopia-correcting or astigmatism-correcting IOL functionality and assume financial responsibility for defined noncovered items and services associated with that choice.^6-9 The distinction between the covered cataract procedure and the noncovered services should be explained before the discussion turns to price.

Language matters. Describing the patient’s choice as a “premium cataract surgery package” may blur the distinction between the covered cataract operation and the additional noncovered refractive services the patient elected. Similarly, telling a patient simply that “the laser costs extra” can be misleading. Medicare does not make cataract extraction noncovered merely because a femtosecond laser is used; the covered components of cataract surgery remain covered.¹⁰

Transparency therefore requires price comprehension rather than just price disclosure. A single total may be easy to present, but it may not tell the patient what is included, what is excluded, or who will send a bill. Experience with price-transparency tools suggests that merely making prices available has limited value when patients cannot translate those numbers into their expected financial responsibility.^11,12

What Determines a Defensible Price?

Transparency raises another question: How did the practice arrive at its price? There is no universal formula for the optimal professional fee. The cost of providing a service matters, but cost recovery alone does not establish an appropriate price. Physician time and expertise, staff expense, technology, equipment, malpractice coverage, compliance infrastructure, administrative burden, bad debt, local market conditions, patient demand, competitive alternatives, and the margin necessary to sustain and reinvest in the practice may all be relevant.

Most of these factors are invisible to patients. A patient may see a relatively brief encounter with a surgeon without seeing the technicians, counselors, diagnostic equipment, surgical planning technology, electronic systems, regulatory requirements, and postoperative availability that make the encounter possible.

Nor does fairness necessarily mean that every patient produces the same payment. Medicare establishes allowed amounts for covered services. Commercial payors negotiate contractual rates. Self-pay patients and patients purchasing noncovered services may encounter another fee structure. Different prices are therefore an ordinary feature of health care in the United States.

A useful question is whether differences are consistent, defensible, and sustainable. Similarly situated patients should generally be treated consistently under the practice’s financial policies. Differences in price should have a rational basis that the practice can explain. And a fee that fails to support the resources required to provide the service is not optimal simply because patients prefer it.

The same economic reasoning applies when a practice considers a prompt-payment discount or other pricing policy. A discount that merely reduces the amount collected has sacrificed margin. A properly designed arrangement might instead improve collection rates, reduce billing expense, accelerate cash flow, or decrease bad debt sufficiently to justify the concession. The relevant question is not simply, “How much should we discount?” but, “What economic result does this pricing policy produce?”

A defensible fee therefore lies somewhere between 2 simplistic approaches: charging only enough to cover identifiable costs and charging whatever the market will bear. Sound pricing considers cost, value, market conditions, collection experience, and the financial sustainability of the practice.

What Does the Law Require?

The law establishes important boundaries around these decisions. The No Surprises Act reflects the broader movement toward prospective financial disclosure. Among other protections, uninsured and self-pay patients generally have rights to a Good Faith Estimate for qualifying scheduled services. Federal rules specify timing requirements, and a patient-provider dispute process may be available when a final bill from a provider or facility is at least $400 more than its Good Faith Estimate.^13,14

Medicare requirements are particularly important in ophthalmology. When a beneficiary selects certain noncovered refractive functionality associated with presbyopia-correcting or astigmatism-correcting IOLs, the physician and facility may charge for defined noncovered portions of the service. The beneficiary should understand the distinction before surgery. Yet within this context, there are limits to a patient’s financial responsibility. Covered components of cataract surgery cannot simply be transferred to the beneficiary because the practice uses particular technology or because the patient elected an additional noncovered refractive service.^6-9 The surgeon’s election of a high-technology surgical instrument or implant does not necessarily mean that a beneficiary can or should accept financial responsibility for it. For example, a surgeon may choose to use a femtosecond laser during cataract surgery for the capsulorhexis without obligating the patient to pay for it, even though it costs more to do so.¹⁰

Payment policies also require care. Routine waiver of Medicare deductibles, copayments, or coinsurance may create federal fraud-and-abuse concerns. That is different from addressing genuine individual financial hardship under an appropriately structured policy.¹⁵ Practices must also recognize patients enrolled in the Qualified Medicare Beneficiary program, for whom federal law prohibits billing Medicare Part A or Part B cost sharing.¹⁶

These statutes and rules are not substitutes for sound pricing. Rather, they establish boundaries within which a practice develops and communicates its financial policies.

How Should the Practice Communicate Price?

Transparency is a process, not a form. The physician should generally explain the clinical choice: what is medically necessary, what is optional, what alternatives exist, and what the patient is choosing. A trained surgical counselor, financial counselor, billing specialist, or other designated team member can then explain the financial consequences of that decision, including exact prices when known, estimated insurance responsibility, facility charges, payment arrangements, and amounts that remain uncertain. Put simply, the physician explains the clinical choice; the financial counselor explains its financial consequences.

That division of responsibility does not relieve physicians of discussing cost when cost affects clinical decision-making. It recognizes that expecting a surgeon to know an individual patient’s remaining deductible, facility fee, insurance benefit design, and payment-plan terms during an examination is unrealistic.

The physician and staff must also use the same vocabulary. If the surgeon describes a service as “optional,” the counselor calls it an “upgrade,” and the billing office later describes it as “not covered,” the patient may reasonably wonder whether everyone is discussing the same thing.

Written information should reinforce rather than replace the conversation. For cataract surgery, the patient should be able to distinguish professional from facility fees, covered from noncovered services, and known prices from estimates that may change. For uninsured or self-pay patients, the practice’s good faith estimate process should be integrated into the same workflow rather than treated as an unrelated compliance exercise.¹³

Payment arrangements require similar consistency. Self-pay pricing, prompt-payment policies, installment arrangements, third-party financing, and financial-hardship policies serve different purposes and should not be lumped together as “discounts.” Each should have defined eligibility criteria, a legitimate financial purpose, and appropriate review for compliance with applicable law and payor contracts.

Consider Ms. Smith again. Before scheduling surgery, she understands that Medicare covers her medically necessary cataract procedure and conventional lens. She has voluntarily selected additional refractive functionality that Medicare does not cover. She understands that the surgeon and facility have separate charges, what she is expected to pay for each, which amounts are estimates, and what payment arrangements are available.^6-9 Her financial responsibility may be exactly the same as it was when she entered the office. What has changed is that she understands it before surgery.

Conclusion

Fee transparency and financial sustainability are not opposing objectives. Rational prices, consistent terminology, clearly assigned staff responsibilities, compliant payment policies, and effective communication can make the patient’s financial experience more predictable while preserving the resources necessary to operate a high-quality ophthalmology practice.

Ultimately, success should not be measured by the number of prices posted on a website or signatures collected on financial forms. The better standard is whether a reasonable patient understands the financial consequences of a treatment decision before receiving the treatment.

Priya M. Mathews, MD, is the director of cornea and ocular surface disease and assistant medical director at Center for Sight in Sarasota, Florida. She reports no relevant disclosures.

Kevin J. Corcoran is a principal and co-owner of Corcoran & Corcoran in Las Vegas. Dr. Corcoran is a fellow of the National Academy of Opticianry and has earned the Certified Ophthalmic Executive designation from the National Board for the Certification of Ophthalmic Executives. He reports no relevant disclosures. 

References

1. Henrikson NB, Banegas MP, Tuzzio L, et al. Workflow requirements for cost-of-care conversations in outpatient settings providing oncology or primary care: a qualitative, human-centered design study. Ann Intern Med. 2019;170(suppl):S70-S78.
2. Sloan CE, et al. How can healthcare organizations improve cost-of-care conversations? A qualitative exploration of clinicians’ perspectives. Patient Educ Couns. 2022.
3. Carroll JK, Farah S, Fortuna RJ, et al. Addressing medication costs during primary care visits: a before-after study of team-based training. Ann Intern Med. 2019;170(suppl):S46-S53.
4. Richman BD, et al. The No Surprises Act and informed financial consent. N Engl J Med. 2021.
5. Centers for Medicare & Medicaid Services. How to Read Your Medical Bill. CMS Medical Bill Rights. Accessed August 15, 2026.
6. Centers for Medicare & Medicaid Services. Medicare Vision Services. MLN Booklet MLN907165. June 2026.
7. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual. Chapter 32: Billing requirements for special services, §120. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c32.pdf
8. Centers for Medicare & Medicaid Services. CMS Ruling 05-01. Requirements for determining coverage of presbyopia-correcting intraocular lenses that provide two distinct services for the patient. Accessed August 15, 2026. https://www.cms.gov/regulations-and-guidance/guidance/rulings/cms-rulings-items/cms026530 
9. Centers for Medicare & Medicaid Services. CMS Ruling CMS-1536-R. Requirements for determining payment for insertion of astigmatism-correcting intraocular lenses following cataract surgery. Accessed August 15, 2026. https://www.cms.gov/regulations-and-guidance/guidance/rulings/cms-rulings-items/cms1192605
10. Centers for Medicare & Medicaid Services. Laser-assisted cataract surgery and CMS Rulings 05-01 and 1536-R. November 16, 2012. Accessed August 15, 2026. https://www.cms.gov/sites/default/files/2021-10/CMS-PC-AC-IOL-laser-guidance.pdf
11. Desai S, Hatfield LA, Hicks AL, et al. Association between availability of a price transparency tool and outpatient spending. JAMA. 2016.
12. Mehrotra A, Brannen T, Sinaiko AD. Promise and reality of price transparency. N Engl J Med. 2018.
13. Centers for Medicare & Medicaid Services. Regulations and guidance. Good faith estimates for uninsured (or self-pay) individuals. Accessed August 15, 2026. https://www.cms.gov/marketplace/resources/regulations-guidance#Good_Faith_Estimates 
14. Centers for Medicare & Medicaid Services. No Surprises: Understand your rights against surprise medical bills. Published January 3, 2022. Accessed September 18, 2026. https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills
15. U.S. Department of Health and Human Services, Office of Inspector General. Special Fraud Alert: Routine Waiver of Copayments or Deductibles Under Medicare Part B. Issued May 1991; republished December 19, 1994. https://oig.hhs.gov/documents/special-fraud-alerts/876/121994.html 
16. Centers for Medicare & Medicaid Services. Qualified Medicare Beneficiary (QMB) Program Group. Updated March 16, 2026. Accessed August 15, 2026. https://www.cms.gov/medicare/medicaid-coordination/about/qualified-medicare-beneficiary-program 

Priya M. Mathews, MD, MPH, is the director of cornea and ocular surface disease and assistant medical director at Center for Sight in Sarasota, Florida. She reports no relevant disclosures.

Kevin J. Corcoran, COE, FNAO, is a principal and co-owner of Corcoran & Corcoran in Las Vegas. Dr. Corcoran is a fellow of the National Academy of Opticianry and has earned the Certified Ophthalmic Executive designation from the National Board for the Certification of Ophthalmic Executives. He reports no relevant disclosures.