By Charles Mok, Jr., DO
Preplacement exams, DOT physicals, injury treatment, drug testing. . . a list of the day-to-day services offered in an Occupational Medicine facility. As the framework for practice, these services offer financial stability and longevity. What if there was an opportunity to generate revenue while offering a specialized service to a niche community? Often overlooked, immigration physicals can be a great way to attract new patients, develop a positive image for your practice, and add variety to a practice.
Individuals applying for a “change of status” with regard to US residency are required to complete an application process and physical examination through the United States Citizenship and Immigration Services (USCIS). These physical examinations are often referred to as “immigration physicals.” Immigration physicals entail screening for “communicable diseases of public health significance” (tuberculosis, syphilis, etc), updating immunization status, medical/psychological history, and a physical examination. The USCIS requires civil surgeons only accept results that can be reasonably verified as belonging to the patient. Hence, most lab results and testing will need to be performed at the civil surgeon’s office. The medical examination itself must include a review of medical/psychiatric history, hospitalizations, and physical examination. The criteria to be included in the examination are defined by the Centers for Disease Control and Prevention (https://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions/civil-surgeons/medical-history-physical-examination.html). Typically, this process necessitates two separate visits (lab collection on first visit and results review, immunizations, and physical on the second visit). Evaluation results are documented on USCIS form I-693.
Only physicians may perform immigration physicals. Applicants are required to use an examiner that is listed as a “designated civil surgeon” on the USCIS website. Physicians seeking to provide these exams must apply through the USCIS (https://www.uscis.gov/i-910 ) and meet basic requirements: unrestricted licensure, a minimum four years of professional experience, and authorization to work in the United States. Following the submission of an application, local USCIS field offices make the final determination if there is a need for additional civil surgeons in a given geographic area.
Patients presenting for immigration physicals may come from any country in the world. Some are fluent in English, while for others language barrier is an issue. This creates difficulty for staff during scheduling and for the physician-patient interaction. It is extremely helpful to have a language translator service available. In typical practices, having staff members that are fluent in languages other than English can meet most needs. This is not the case for immigration physicals. In the author’s facility, some of the languages encountered that required translation included Macedonian, Vietnamese, Arabic, Chinese, Japanese, Korean, and Portuguese. It is unlikely any one facility can have a sufficient variety of translators to meet all needs.
Cultural differences and expectations may pose hurdles to completing the process. For some patients, this is their first experience in the US healthcare system. They are not familiar with the expectations or “etiquette” of the physician’s office. Patients may come from countries where bartering is common practice. At the time of fee collection, these individuals may attempt to barter with the receptionist. This creates confusion with staff members who are accustomed to set pricing for services rendered. In other situations, patients may be offended or refuse an exam by a physician of a different gender. Although this is common practice in US physician offices, some patients interpret this as an insult to their modesty. Such awkward situations can be avoided through cultural sensitivity training and prior explanation of immigration physical components and expectations.
From a business perspective, immigration physicals provide a straightforward source of revenue. The menu of services is limited by the requirements of the examination. This allows the practice to create an “a la carte” pricing matrix. Staff can communicate this information to the patients, so they will know their charges upfront. As the patient provides payment at the time services are rendered, this reduces overhead costs for billing/collections and stabilizes day-to-day cash flow. Finally, “positive patient experiences” serve as low-cost advertising. Word of mouth can attract referrals from friends and family members of patients or immigration attorneys.
Performing immigration physical exams can be rewarding, fiscally and professionally. As most services are provided on a “fee for service” basis, payment in full is received at the time of the exam. Professionally, it provides an opportunity for the physician to introduce the patient to the US healthcare system and the patient to provide a glimpse into their own culture. Understanding the unique skills required for this exam can help to overcome initial challenges. Beyond that, civil surgeons are providing an incredibly valuable service for the community. Many of the patients who seek immigration physicals are experiencing the U.S. healthcare system for the very first time. Physician and staff preparation facilitates a smooth, stress-free process.
