What do you need to know before starting a vision therapy practice? This article will answer many of the questions and uncertainties that you might have throughout the process.
How many sessions should be in a vision therapy program?
How many vision therapy sessions does it take to treat a patient? This is a how-to guide to help answer that question for vision therapy practices.
What is the appropriate length of a vision therapy program?
In my opinion, this can be the hardest question to answer as it is not always straightforward. Once you’ve completed your vision therapy work-up and know your patient needs vision therapy, you not only need to determine a type of treatment program, but the length of the program. In order to do so successfully, you must consider all of the diagnoses, and then consider other nuances that may change your course of treatment.
Below, you will find all of the critical elements I consider before making a recommendation on the length of a vision therapy program.
This is the easy part and is determined by your basic vision therapy workup that typically includes:
- Cover test (distance and near)
- NPC (accommodative vs. non-accommodative)
- In-phoropter phorias (distance and near)
- Vergence ranges (distance and near)
- Near Add (if necessary)
- Accommodative Amplitudes (minus lens)
- Vergence Facility
- Accommodative Facility (Mono/Binocular)
As well as your visual information processing (perceptual) portion of workup that typically includes:
- Oculomotor Function (DEM/Visagraph/King Devick)
- Visual Memory (simultaneous and sequential)
- Visual Motor Integration
- Visual Discrimination
- Visual Closure
- Form Constancy
- Screening for a possible reading disability
Finally, I highly recommend adding a full perceptual workup to your evaluation. Although time-consuming, it gives you a tremendous amount of information about the patient and how they are using their eyes. An article I wrote on the COVD Blog
last year highlights the importance of visual perceptual issues.
2. The “other factors”
This is perhaps the most difficult piece to ‘learn,’ but some of the things I consider are:
- Maturity Level
- Developmental Delays/Missed Milestones
- Other diagnoses such as: Autism, PDD/NOS, Dyslexia, Post-Concussion, Psychological
The more vision therapy evaluations you perform, the more you’ll get a sense of the contributing factors that may affect how a person will respond/perform in therapy.
3. Science + art: Determining the number
If you use Clinical Management of Binocular Vision, by Scheiman and Wick, as a reference, they give you a criteria for determining the amount of sessions per binocular disorder. Most of the common binocular and accommodative disorders rank between 12-24 sessions depending on the severity. My method for compounding diagnoses are to determine the base number of sessions for the primary diagnosis, and then for each additional diagnosis, I will add 1/2 – 3/4 of the total recommended sessions. You have to remember that you will be addressing multiple binocular functions within each session, so you do not need the total amount for each diagnosis.
For example, your patient has a moderate convergence insufficiency, a mild accommodative insufficiency and a moderate oculomotor dysfunction. The base number of sessions for the CI would be 16, and then an additional 16 needed for the combination AI/OMD, for a total of 32 sessions. This might seem confusing, but you’ll get the hang of it!
My biggest piece of advice here is to have a conference with the parents a few days after the vision therapy work-up. This gives you time to consider all factors related to the case, write up a report and make a recommendation for the amount of vision therapy sessions with confidence. Some parents might push you to give them a ‘ballpark.’ I usually just respond by saying that I definitely think vision therapy is needed (if it is!), and that I need some time to look at all the pieces of the puzzle to ensure the program will meet the patient’s specific needs.
On a side note: Strabismus is an entirely different beast and is really case by case depending on many factors including frequency, size, type, correspondence, etc… Because there are so many variables, it is hard to make a methodology for this group of patients. Consider all factors relating to your specific case and then determine from there what you want to do.
So, how many sessions do I prescribe?
The typical session amounts that I prescribe are 12, 16, 24, 32, and 36. I find that the two end pieces here are the easiest to recommend: 12 for a straightforward case, 36 for a person who is a ‘visual disaster.’ The in-between session amounts are the ones that take a little bit of practice to get right. If you are between a number of sessions, I always recommend to err on the side of caution and prescribe more. It is much easier to tell a parent that their child did so well in therapy that they are going to finish a few sessions early, rather than to try and tack on more sessions at the end. If you are really unsure of a case, recommend a trial of 12 sessions, and see how the patient responds. At the re-evaluation, you’ll be able to determine how much progress was made and from there, you can determine the remaining course of therapy.
What I can tell you is that the mastering of prescribing a vision therapy program takes time and practice, but is an essential part to guarantee your success.
Stay connected and follow up with your patients
Staying connected to your vision therapy patients through emails, reports, and Facebook gives you the opportunity to stand out among your peers! This will help you follow through with your patients.
One of the most important things I have learned since I graduated has been that all patients appreciate follow-through, and I strive to do so with all of my vision therapy patients.
If you say you are going to do something, do it. You are the only one in control of building up your patient base and making a name for yourself in the community. A good way to do that is to become accessible to your patients and keep an open line of communication.
How to follow up with your patients
I encourage ANY doctor to apply these recommendations when possible and take that extra step in patient care!
This is a big one. I am constantly emailing information to my patients. For instance, if I discover a child has a convergence or accommodative insufficiency in a primary care exam, I will educate the parent on treatment options. This may be a bit overwhelming, so I ask for an email address to send the parent/patient information for them to review what vision therapy is, and include articles/sites describing the particular condition as well as access to other informational websites.
Here is a sample email that I typically send out to my patients with a CI:
It was a pleasure to meet you and your son Jonny! Below you will find some links about vision therapy in general, what convergence insufficiency is and a wonderful YouTube video explaining vision therapy and how it relates to learning.
- Here is a link to a description of vision therapy:
- Information about convergence insufficiency
- YouTube video mentioned above:
As a side note, if you are on Facebook, the COVD page and the Vision Therapy Parents Unite page are great resources!
Looking forward to our full vision therapy work-up for Jonny on X/X/X at X. I am confident that we can get to the root of the problem and work towards getting Jonny more visually comfortable! If you have any questions or concerns, please do not hesitate to contact me!
Miki Lyn D’Angelo, OD
I also encourage sending follow-up e-mails throughout the course of treatment and beyond. This gives our patients the sense that we really do care and are here if they ever have any questions!
Make template e-mails for common conditions! This helps save you time!
2. Reports and consults
A full vision therapy work-up is costly and time consuming on the patient's part. I believe that you need to write a detailed report that reflects that to ensure that the patient feels like it was money/time well spent and feels comfortable with the treatment plan. Included in this, I always ask whom else I should send a report to (PCP, school psychologist, OT/PT, speech therapist, etc...) so that I can keep everyone on my patient's "health care team" involved.
The second part of this is what I refer to as the "vision therapy consult." I bring the patient/parent back a few days after the initial work-up to discuss all the findings and present the report in person. The period between exam and consult allows everyone time to digest the exam, think of questions, and affords me an opportunity to really consider all aspects before coming up with a treatment protocol. I typically set aside 30 minutes of uninterrupted time to meet with my patients to describe each condition in detail, show examples of how their child is seeing and what the plan is for remediation. Taking this extra step conveys to your patient that you care and are there to see them/their child succeed.
Take caution to not let your report writing fall by the wayside after the initial workup. Keep up with progress reports, documenting improvements, and any changes in treatment plans!
You must set aside time to write reports/correspond with patients. Give yourself a few hours of administrative time each week to get these tasks done.
I encourage patients to go on Facebook to read and talk to other parents/patients about vision therapy. Due to the fact that many people are not familiar with VT, giving people a forum to learn and feel comfortable with the practice modality is a must in my book.
I also recommend that you keep the practice’s Facebook Page up-to-date. Make daily posts about optometry, what is going on at the practice and even success stories! People like to feel connected and Facebook is the go-to place to do that.
At the end of the day, staying connected with your patients is what is going to set you apart from the doctor down the road. Taking that extra time to send an email, write a report or spend an extra few minutes talking to them is really what makes the difference. Be the doctor that patients can't stop talking about!
Happy patients lead to referrals
Throughout my residency year I learned that a vision therapy program is only as strong as its referral sources.
If you do not have the patient population within your own office to self-refer, you must educate the surrounding doctors about your skillset, what services you offer, and when to make a vision therapy doctor referral.
So where do you even begin? Here's a list (my personal to-do list actually!) on how to rally your vision therapy referral sources:
1. Send letters, make phone calls
This may seem simple, but it goes a long way. Sending out a letter introducing yourself to fellow optometrists, pediatricians, occupational therapists, physical therapists and even primary care physicians gives you the opportunity to share what your specialty is and what services you offer. All you need is for one of those doctors to respond to your letter, reach out or send a patient your way. An editorial written by Paul B. Freeman, OD (former editor of Optometry)
sums up perfectly the importance of a proper vision therapy referral in this article
written in 2011:
"Certainly, all therapies do not work for all patients all of the time, but no therapy will work for anyone if that person is not given the opportunity to explore the legitimate alternatives to apparently ‘unresolvable’ visual complaints form a patient with a ‘healthy’ pair of eyes …. In the case of vision therapy, there are evidence-based protocols to support such intra-optometric referrals. And who knows? Someone reading this editorial might well be the next practitioner to change someone’s life through such a referral.”
Here is a letter that I am penning and planning on sending out to surrounding doctors in the area to educate them about who I am and what services I provide.
Another option is to send out letters offering to do school screenings. Here is a School Screening Letter
that I wrote offering my services to the local school districts. We have had GREAT success with this. We got into three schools, which has brought in a ton of new patients, grown our pediatric/young adult population and has even spawned some vision therapy evaluations!
2. Event calendar
I feel like January is the time to write lists. Lists of your resolutions, goals and now... a list of marketing tasks that you want to accomplish month by month. My "Creating a Business Plan
" article details this in the marketing category.
3. Talk to your COVD mentor
COVD offers a match
program that puts you in touch with successful vision therapy doctors around the country. In this instance, you can contact any of the doctors (not just the ones in your area) and talk to them about what they do to bring in vision therapy referral and how they build their therapy programs. Sometimes it isn't about reinventing the wheel, but rather learning from those who have done it already and model it after their successes.
I saved the best for last. In-services allow you to invite your target audience to listen to what services you provide and when to make the appropriate vision therapy referral.
You can do this one of two ways:
- You invite them to the office after-hours for a one hour session
- or you can offer to come to them.
Either way, it allows you to talk with potential referral sources on a one-to-one basis and gives them the opportunity to see what you do. I usually structure my in-services to have a 30-40 minute powerpoint presentation and then a 20-minute question and answer portion.
To network for these you can send out letters, make phone calls or even send out "E-Invites." I have used Eventbrite
in the past to help spread the word about upcoming events via social media. For those of you not familiar with EventBright it is an E-Invite site that is free to sign up and use (as long as you don't charge for tickets to your event!). There are many options within the site, but it is an easy tool to help spread the word via email, facebook, twitter, etc...
As I had said earlier, your vision therapy business is only as strong as your vision therapy referral sources. Putting the extra effort into educating your close optometric colleagues and other health care professionals when a referral is appropriate will only make your business stronger. As always, the relationships you create are ones that must be maintained. Keep the doctors that refer to you in the loop with constant correspondence about patients they send to you, create a newsletter highlighting success stories, and make referrals back when appropriate.
Finding your own vision therapy patients
There are four easy ways to identify vision therapy patients within your primary care population. These are the tests I commonly use.
The question I get asked the most about starting up a vision therapy practice is, “Where do I find the patients?”
To be honest, this is the easiest part! Your vision therapy patients are right there in front of you! The key is to know what questions to ask and which screening tests to do!
Even if you aren’t planning on doing therapy in your office, this list is also a great way to spot a potential vision therapy case. Making the right referral for a patient can change their life and in return, you will have gained a whole family worth of patients.
Here are four easy ways to identify your ‘at-risk’ patients:
This is by far the easiest addition to your workup, with the highest rate of return. Give out this questionnaire to your patients as part of their entrance paperwork. It takes the patient a few extra minutes, but gives you a wealth of knowledge about your patient.
My favorite vision skills screening questionnaire is the COVD
- Quality of Life Survey.
This survey has been tested and re-tested with good repeatability and reliability for accurately identifying 'at-risk' patients. The cut-off score for the 'at-risk' patient is anything over 20.
Of all of the literature written on this survey, this paper
, written by W.C. Maples, describes the most frequent and severe symptoms reported in the pediatric population. A must read!
You can give this survey to every patient that walks through the door (my recommendation), or only to those patients that are 18 years and younger. Whatever you choose to do, train your staff to highlight and inform you of the patients whose scores are high on the survey before you enter the exam room. This allows you to ask follow-up questions and perform additional tests to determine if a vision therapy evaluation or referral is warranted!
2. Cover tests:
This might seem like an obvious thing to do, but I can't assume that every doctor is doing an accurate cover test at both distance and near on every patient. This test takes maybe an extra minute to perform, and gives you a wealth of information on how your patient functions.
For those that do not remember how to perform an accurate cover test (both unilateral and then alternating). Remember the keys to performing an accurate cover test are good fixation, proper occlusion, and patience.
I find that many patients have a moderate sized exophoria at near, that will easily break down into an intermittent exotropia. If you see something like this, you can start asking your patient follow-up questions to determine if they are symptomatic. You will be surprised at how many people see intermittent double vision at near and think it is normal!
3. Near point of convergence (NPC):
Near point of convergence can give you so much information about a patient's convergence ability, visual stamina, and recovery ability.
If I had to choose one test to perform to determine potential vision therapy patients, NPC would be that test.
With your fixation target in place for the cover test, you can then flow right into measuring near point of convergence. In case you need a reminder, I wrote an article a very long time ago, detailing how to perform NPC
. The key here is to repeat the test more than once, and not to rush through it.
Author’s Tip: There are a multitude of targets you can use to test NPC, but my two favorites are a pen tip (my accommodative target) and a penlight (my non-accommodative target)!
4. Accommodative amplitudes:
With the visual demands of today, our accommodative system is constantly and consistently being utilized. Many people experience intermittent blurred vision, and think it is normal because their eyes are "tired." We know this is not the case, and understand the true underlying cause of this.
Although some might argue that NRA/PRA gives you more information, I like to isolate the accommodative system from the binocular system in this instance. Performing a quick minus lens amplitude after you do some near testing can highlight a patient suffering from accommodative insufficiency.
To perform this test, make sure your patient is fully corrected, and use an accommodative target at 40cm (16 inches) with good lighting. Occlude one eye and slowly start introducing minus, making sure to ask your patient to occasionally re-read a line on your target to ensure they are fully clearing the line. Push the patient to their limit of blur and then calculate the amplitude (don't forget to account for the 2.5D of accommodation already instated with the target). Repeat for the other eye.
Figuring out the status of your patient's accommodative system may affect the way you prescribe glasses, and also opens up the conversation about vision therapy.
Disclaimer: Every patient you flag may not need or want to do therapy. You have to use your clinical judgement on when to make the internal or external referral for a full vision therapy work-up. I often compare the clinical findings with the symptoms survey and follow-up questions, and then determine the patient’s motivation for change.
Just remember the key to success in vision therapy is awareness: your awareness of patients at risk, and their awareness of the services you provide!
Staying aware of advances in the field
Here is a list of my top five ways to learn and stay connected with the advancements in vision therapy and rehabilitation.
The most frequently asked question I hear is, “I did not get a lot of exposure to vision therapy, where do I start to learn (or re-learn) about vision therapy?”
Below you will find my top vision therapy books for understanding, learning, and keeping up with all things related to vision therapy and rehabilitation.
*Disclaimer: I am not employed by any of the organizations mentioned below, or have financial interest in any of the books or journals listed. They simply are my favorites.
1. My go-to books
This book has been my all time favorite reference throughout my vision therapy career thus far. It gives the most comprehensive assessment and management of any binocular vision disorder in a simple, concise, and easy-to understand way. I find that difficult concepts that are often avoided in other texts are addressed well in this book. This is the book I recommend for any optometrist that is interested in having a solid understanding of the binocular system.
This was a required text when I was studying in optometry school and I now understand why. It has been the foundation for my diagnosis and management skills in vision therapy. It clearly lays out each common binocular vision condition, describing symptoms and what the management plan could be. It also provides a sample vision therapy program for each condition.
The best way to stay connected to your profession and all of the advancements that occur is to read as many journals as possible. I recommend that you subscribe to one of the major journals that covers the entire profession as well as two or three in your particular area of interest. For me, these are my go-to’s:
Blogs are the way of the future! They are great resources for daily posts, case studies and different areas of discussion. I subscribe to these blogs and read their articles almost everyday!
This blog is managed by Dr. Shelly Mozlin, who is passionate about spreading the word about everything related to vision and learning. This results in a blog that reflects just how pervasive visual issues can be. What I really like about this blog is that there are many guest writers that have different areas of expertise, resulting in a blog that is comprehensive and effective at educating in all areas related to vision. In addition, it is organized by topic which makes it easy to find specific things you may be interested in.
Dr. Leonard Press is the most active writer on this blog, posting on a daily (sometimes bi-daily!) basis about all sorts of topics. Typically, his posts are short, sweet and to the point with a lot of discussion in the comment sections.
The Concussion Project is a website created by the team of doctors behind the VisionHelp Blog that serves to educate optometrists and parents/patients alike about the visual effects of concussions, treatment protocols, and management plans. It is a phenomenal reference for any new graduate looking to work with this specific population.
4. COVD meeting
5. COVD match
This program has become my favorite part of NewGradOptometry.com. I think it is amazing that we are connecting new graduates to local (or not so local!) doctors to act as their mentors and confidants. I talk to my ‘match’ on a weekly basis! Visit the site today and get in touch with an associate or fellow of COVD.
Check out these COVD Resources:
- Learn what COVD has to offer students and residents!
- Sign up for your FREE COVD membership here!
- Already a member of COVD? Access programs and benefits here.
- Come experience the ‘COVD Family’ in person this April–Travel Grants available!
All about insurance
Do vision therapy practices need insurance?
So you've decided to forge forward with vision therapy, you are excited, have a business plan ready to go and then comes your first big business decision: do I take insurance for vision therapy or not? This question was one that I mulled over for weeks (if not months) with myself and as many vision therapy doctors as I could get in touch with. I am in no way an expert on billing/coding, but what I can share with you is my experience with this question and how I came about my decision.
So let's get a few basics out of the way...
- With any service that you provide in your office, you have the decision to be on an insurance panel or not.
- You can still see patients that are not covered under insurance, but it will be an out of pocket expense to those patients.
- If these patients have “out-of-network” benefits, they can submit your exam to their insurance for reimbursement.
- Most doctors bill an office visit (92012) and an orthoptic training (92065) code for therapy.
- Some doctors offer Vision & Learning” sessions that addresses the perceptual aspects to vision. This is never covered by insurance as it is considered ‘educational.’
- Other options include 97000 codes for rehabilitation (I am not familiar with these, but click here for a great article provided by COVD’s practice management series).
Now that we have those facts out of the way, let's talk about our options:
1. Take insurance
This seems like the easiest option, right? You are most likely already on the big insurance panels for your primary care patients, so why not offer vision therapy as a service through these panels? In a perfect world, this would be the best option- your patient gets the service they need through their insurance and you get reimbursed for your services. Well, it is not that simple.
In 2014, no insurance plan is straightforward. Patients have high deductibles, large copays and many services that are not covered. Each plan for each patient is different, which means you have to be the detective to determine if the insurance company will cover the service and the diagnosis code. For every patient, it is recommended that you speak to the insurance company and determine prior to starting therapy whether the service is covered or not. This may take weeks, but you do not want to tell a parent that therapy is covered and then 8 sessions in find out you are getting denial letters. When this happens you are left with two bad results- an angry parent that technically owes you money and a kid that has started therapy, but may not finish.
Don't get me wrong, taking insurance for therapy isn't all bad. Once you have figured out a system to see if therapy is covered or not, you will be better geared to deal with the parents and present all of the options to them. Taking insurance does
allow you to see your primary care population without a problem. In the beginning while you are building up a reputation in the community, taking insurance helps tremendously in building your patient base. My advice is if you are going to accept insurance for therapy, don't get on EVERY panel. Some panels are known to pay more than others, but each region varies. I recommend using the COVD Mentorship Program
to touch base with a doctor in your area to see if they have advice for which panels are worth dealing with.
As I stated earlier, some doctors break their therapy programs into "orthoptic" sessions and "vision and learning" sessions on an alternating basis. These vision and learning sessions address oculomotor activities, visual memory, spatial relations, laterality and directionality and other perceptual areas. In my experience, the perceptual portion is the key to unlocking a child's full visual potential (an article I wrote for the COVD blog
describes all of these areas and why they are important). With that said, these vision and learning sessions are not covered by insurances. From the doctor's perspective this guarantees at least half of the vision therapy program will be paid for up front, which may offset the low reimbursements from the insurance companies.
- Build population base
- Offer services to many patients
- Able to see primary care
- Getting approval may take weeks
- Possible withdrawal of payment
2. Don't take insurance
Now that I've gone through the battles of taking insurance, you're going to think well " taking no insurance is a no brainer." Well, again this option has its pros and cons as well.
Vision therapy is not cheap and unfortunately many people don't always have extra money to spare, no matter how valuable they think your service is. For example a typical vision therapy program is say anywhere between 24-32 sessions. At $125/session, that is $3,000-$4,000 dollars, not including maintenance material and re-evaluations. Offering service such as Care Credit
(a medical financing program) to patients does help to offset the blow a little bit.
On top of the large cost to patients out of pocket, how are you as the doctor going to offset the time you are not seeing patients? In the beginning you are going to be building up your vision therapy, but probably not making a ton of money. Most optometric practices' bread and butter is primary care.
If you aren't on any insurance panels, will patients come in to see you and pay out of pocket?
These are all questions you have to ask yourself before jumping ship on insurances.
Each doctors situation is different. If you are in a group practice, it might be easier to stay off insurance and just see those private pay patients. You can also work only when you have a vision therapy evaluation or therapy.
The pros are easy here: no hassle of dealing with insurances to determine if the service is covered- the price is what it is and your patients can decide what they want to do, the amount of money coming in from the business is straightforward and you have a bigger commitment from your patients because they are actually paying for the service.
- No dealing with insurance companies
- Straightforward reimbursements
- Increased patient commitment
- May lose patients that can’t afford therapy
- Can’t perform primary care services (unless private pay)
When I first presented my business plan to my boss, I pushed for him to keep me off of insurance panels. We decided on a trial period of me not on insurance panels- a small victory in my book!
Well.... a month later I wasn't holding up my end of seeing enough primary care (our office does not have many private pay customers) and we had to find a middle ground. The agreement was that I would join certain panels (not all) that I knew reimbursed well enough for both primary care and vision therapy. There were two catches to this agreement. One, my boss had to understand that we may lose money on some patients due to low reimbursements for the therapy. To offset this we decided to run our therapy sessions while another doctor was seeing primary care. The second catch was that once I was booked up for evaluations 2 weeks in advance and needed to add times for vision therapy, I could start coming off certain panels.
I often have to remind myself that anything worth doing isn't easy!
I mulled over this question for weeks, even months before coming to my decision. Then a month into working full-time I had to change my game plan I had spent so much time working on. Depending on your situation, your decision may vary from mine. You have to do what works for you and your business!
As with anything, you have to make things your own. This article was designed as a vision therapy resource to help you start thinking about the things you need to consider when starting a business; specifically, a vision therapy practice.
And there you have it! A lot of information, but now you're set to start your own vision therapy practice! If you have any questions, please feel free to comment and I will do my best to answer them! Good luck!