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 By Neil B. Gailmard, OD, MBA, FAAO, Editor March 19, 2003 - Tip #61 
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Getting Insurance Information Over the Phone

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Additional Information

A colleague asked if I had any suggestions for verifying patients' eligibility for vision insurance benefits. He brought up the often-faced dilemma of finding out about insurance at the time of the exam (or worse yet, after the exam) and how the doctor's schedule can be destroyed while waiting to confirm eligibility. This might occur because patients fail to mention insurance when they schedule the appointment, or if they give incorrect information over the phone and need to update it in person. I do have a few tips on this topic - and it is an area that I believe our practices should continually work to improve upon.

Since there are so many aspects of managed vision care that we have no control over, we must become absolute experts at controlling what we can. We must do all we can to be efficient and accurate, because profit margins on this part of the practice are so slim. In my practice, this starts with discussing insurance benefits, fees and payment policies over the phone.

This requires detailed staff training. Here is a list of how we handle gathering insurance information over the phone. You might want to use it as a checklist in a meeting with your staff to see if you could improve your procedures.

  • Ask every person who makes an appointment if they have vision or health insurance that they intend to use at their visit.
  • If they say yes, we determine the type and then inform the patient if we are providers for that plan or not. If you accept many plans, you might want to print a list of those plans and post it at the front desk - for staff to refer to and for patients to see. I would not make any exceptions to this list.
  • If we are participating providers, we ask for the social security number or insurance ID number and any other information that is needed for us to obtain eligibility in advance. If the patient can't provide us this information, we politely inform him that we can't bill the plan without verifying eligibility in advance, and then we quote our usual exam fee and advise the caller that the fee is due at the time of service. Some people decide to find out the information and call us back.
  • The above approach might seem like a hard line, but my staff has become expert at it, and they present it in a way that conveys that it is in the patient's best interest to verify eligibility. Besides, I would rather have the patient not schedule the appointment than show up at our front desk without valid insurance and not prepared to pay the fee.
  • If the patient names an insurances plan that we don't accept, we inform the caller that we are not providers for that plan, we let them know that they will have to pay us at the time of service and they may be able to file their own claim for out-of network services and be reimbursed. We always quote the exam fee, even if not asked.
  • If the caller provides us information on a plan we accept, my staff checks eligibility of benefits immediately and keeps a record of the information on file. If the patient is not eligible for an exam (this occurs when he has previously used his benefits - but also when the information given was not correct) we call him back right away to let him know. We inform him that he can still keep the appointment, but we quote the exam fee and explain that payment is due that the time of service.
In my view, patients deserve to know and need to know what our fees will be if we are planning to ask for payment. They may not know enough to ask about fees - or may be happy to avoid the topic - but we are better off taking the initiative. Taking the proactive approach saves time and reduces bad debt.

Best wishes for continued success,

Read Past Tips Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week

A Proud Supporter of

Send questions and comments to neil@gailmard.com.

Dr. Gailmard offers consulting services to eye care professionals through Prima Eye Group; information is available at www.primaeyegroup.com.
Advertiser Disclaimer: ACUVUE® 2 COLOURS™ is a registered trademark of Johnson & Johnson Vision Care, Inc. © JJVCI 2003. All Rights Reserved.

Please Note: The views expressed in Management Tip of the Week do not necessarily reflect those of the sponsor.

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