We’ve all been there. Your staff asks about insurance when an appointment is scheduled by phone, but the patient says he doesn’t have a vision plan and insists the exam is just routine. Your office asks again at the appointment confirmation and again at check-in, but the answer is still no insurance. The exam is done and new glasses are ordered and the patient acts like all is well. But sometime later, maybe several weeks later, the patient (or the spouse) calls to say “Oh, darn! It turns out we did have vision insurance after all! Please file for my benefits and refund what we paid.”
For the practice owner, that is quite aggravating to say the least! It is not just the staff time that would be required, but this transaction already occurred as private pay and to reverse that and accept the discounted vision plan benefits would mean a loss of revenue.
I want to acknowledge that this topic was sent to me as a question via email by a colleague and I appreciate the idea for this article!
How should you handle this?
Here are your options as I see them:
You could politely tell the patient that it is his responsibility to let your office know ahead of time what insurance/vision benefits he has and there is nothing you can do.
You could tell the patient to file his own claim for out of network reimbursement. But that reimbursement is much lower than in-network benefits and most patients know that.
You could honor the patients request; call the insurance company; find out what they allow in these cases; bill the insurance company and refund the patient.
I would choose the last option, but I realize that will not be a very popular decision with most eye care providers and staff members. It is, however, a very popular decision among patients. Read on for my reasoning on why I let the customer win on this issue even though my profit will be reduced.
To some extent, your options may depend on which vision plan is being used. Some plans allow you to correct an oversight in special cases and file a claim for glasses even if they were made by an out-of-network lab. Some plans do not allow a claim to be filed if the glasses were not made in its lab.
Who is to blame?
When problems occur in my practice, I look at how my staff and I can better control the situation and prevent it in the future. I don’t expect much from patients and I rarely blame them for the problem. Even in this situation, where it seems so obvious that the patient caused the problem by not knowing about his own vision plan coverage and by not telling us about it up front, I look at what my practice did not do well enough. I can’t control how the public thinks and I accept their shortcomings. It is just human nature. But I can control what we do in our internal process of scheduling appointments and getting insurance authorizations.
It will seem odd to many readers, but when this happens in my practice, I view most of it as our fault. We should have prevented it. So, I’m willing to learn from this mistake and help the patient on this isolated incident. Staff members will struggle with this because they hate to admit they make mistakes, but I’ll help get past that by not blaming the individual, but instead blaming our office process.
It is OK if we disagree on how to handle cases like this, but I will remind you (in my defense) that customer service is the biggest factor in building a large, successful, profitable practice.
How to prevent this
By working with my employees on this issue at staff meetings, we came up with a system that makes it extremely rare for us to have a patient tell us later that they have a vision plan.
Our staff member who makes the appointment is responsible for getting the insurance authorization that same day. We know who that was because her initials are on the appointment notes. We never wait until the day of or the day before the appointment.
We assume all patients have a vision plan even if they say they do not. We check all our plans online until we find the patient. Quite often the patient’s employer gives us a clue about the plan. This requires that we get the last four digits of the social security number, but most patients give us that over the phone when we tell them we want to make sure they do not have some coverage.
We call patients back if they do not have insurance and we discuss our exam fee and medical insurance.
In addition to just checking the plan directories yourself, there are various software programs that can assist your staff with finding out if the patient has insurance coverage and in some cases these programs can tell you about co-pays and deductibles.
Best wishes for continued success,
Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week
Dr. Gailmard's new book, Practice Management in Optometry: A Blueprint for Success Based on the Optometric Management Tip of the Week, is now available on Amazon.