INSURANCE Catch 22

Insurance programs have created an awkward situation for both providors and purchasers to work around. Our practice does not treat folks any differently if we are being reimbursed through insurance proceeds or if the patient is paying out of their pocket. However, it always seems that folks don't want to tell us they have insurance until we confirm a price.

Although we have eyewear packages which are discounted with frame, lenses, and options purchases we can not afford to extend both the package discount and insurance discount. We therefore have a policy where only one discount applies. Although this is posted on the package price list we continually have folks coming back for dispensing with their insurance card and saying "OH BY THE WAY I have insurance which covers my eyewear purchase" Unfortunately, this causes everyone to march to the beat of a different drum as they find out it does not necessarily lower the cost of their eyewear and we have to void the sale and are blessed with more insurance paperwork.

My problem with asking if they have insurance before working up a price is many people that actually don't have coverage believe they do or hope they may get lucky to find out they do and expect us to find out. This creates additional time during the sale and even a long wait on the telephone before we even connect with some companies. Then after giving the appropriate information we get a pleasant "SORRY CHARLIE" explanation from a representative indicating no coverage.

I believe there is a happy medium which will enable a mutual benefit of everyone involved.

Thoughts Appreciated

Kevin

Thats a pretty common thing I think
for most places, I know I've had it
done to me a few times (it just keeps
you on your toes). I usually just
keep my prices low enough that
even if they priced me out somewhere
else with their discount I'm usually
still lower.:D

What is the Catch-22? Either they have insurance and that's it, or they are self-pay and get the discount.

I don't understand why your patients expect a discount on top of their insurance. Don't they realize:

1. Their insurance is already paying for part of their bill. That is their disount. (I know...they aren't happy with that, they want more. These people are trying to get something for nothing. I have a real problem with people like that.)

2. Maybe they don't know or care that the insurance most likely doesn't reimburse you your full fees, so how can they expect you to offer a disount on top of reduced reimbursement.

I get so annoyed at people like that. If they have the nerve to try to take advantage of you, then you should have the nerve to stand up for yourself. I'm sure you do, but I mean you definitely should not sound the least bit apologetic. "Package programs are for self-pay patients only. If you prefer the package program, then we can not file your insurance." The choice is theirs.

Before the order is written up, you should ask and ask again, if they have insurance. If they say no, maybe even have them sign a self-pay form to call their bluff, or hold them to it. You simply have to find out before the transaction occurs, what their situation is. Remember, you can't "let the inmates run the asylum."

You said, "My problem with asking if they have insurance before working up a price is many people that actually don't have coverage believe they do or hope they may get lucky to find out they do and expect us to find out. This creates additional time during the sale and even a long wait on the telephone before we even connect with some companies. Then after giving the appropriate information we get a pleasant "SORRY CHARLIE" explanation from a representative indicating no coverage."

You NEED to find out beforehand or else you will have the problem at dispensing that you've been encountering. You have to decide, do you want a quick sale with the risk of them saying at dispensing "Oh by the way I have insurance", or do you want to know upfront, even if it takes time, so you don't have that problem later on. I'm not really sure what happy medium you are expecting to find. It's not your fault if the pt has no coverage, and I suspect your patient knows that already; he's just hoping somehow you will "find a way." You need to take control of these people. If the patient wants a quick transaction, he should come in prepared in regards to his insurance.

P.S. Can you tell I'm in a bad mood? But I stand behind everything I've said, although I may be stating it strongly.

After having re-read my rant, a question comes to mind which makes it all a moot point: are you even "allowed" to sell glasses at one price to insurance pts and another to self-pays. I always thought insurance companies required the fees and charges you submit to them to be the same price you charge self-pays.

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Very interesting comments.

I probably need to clarify the fact that when asking the patient if they are using insurance sometimes suggests the fact that they indeed may have insurance which pays toward their eyewear as they take the next 10 minutes to review every card in their purse or wallet and thus creating the problems mentioned in my initial post.

Provider participation with most insurance companies is a contractual agreement to sell eyewear to their members at a specific price or at a discount off your STANDARD PRICE. Since your cash paying customers are not their members and therefore any discount you offer cash paying customers off your STANDARD PRICING is outside the parameters of the contract and none of their business.

I personally don't have a problem with not accepting third party payments am optomistic that it is reality in the long term. However, we now must face the fact that we are not on a level playing field when the same folks administrating the third party plans also have a vested interest (ownership) in the retail arena. Almost every major retail chain now has their own insurance or vision benefit plan which is brokered out to regional insurance carriers. So what it comes down to is that they can increase their prices, give the plan benefit discount, but also collect insurance premiums from the plan members and/or employers which more than makes up for the discount adjustment. Unfortunately, this influence has caused many retailers to participate with third party insurance plans in some way in order to remain competitive and maintain the goodwill of their business for the short term.

I actually believe some folks are beginning to realize most vision insurance plans are WORTHLESS. For example: Here in PA a person has $5/week deducted from their paycheck for one of the popular vision insurance programs. They are then eligible for one pair of eyewear every 24 months which reimburses $24 for a frame and $24 for SV lenses. Now doing the math: $5 X 104 weeks (24 months) equals a whopping $480.00.
IF I COULD ONLY OPERATE ON THESE PROFIT MARGINS I WOULD BE TOWING THE NEW BOAT HOME TOMORROW!

Kevin

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Gary,

Actually legislation has impacted the way these companies do business; but for the worst. Insurance programs sold in our state must be approved by the PA insurance Commission. However, most third party programs we are discussing are not sold as "Vision Insurances" but are usually an add on to an existing medical or dental plan and termed a "Vision Benefit Plan" These are usually tacked on as a "special" feature during negotiating leverage to companies which are looking for the best benefits for their employees in order to be competetive in the job market and then presented to it's employees under the mask of "VISION INSURANCE"

Now as you know with auto insurance if you are unfortuante to be involved in a fender bender your insurance company pays a usual, customary, and reasonable fee for your auto to be repaired and usually have no interest of where the work is done. That is INSURANCE that your problems are taken care of.

Likewise Vision INSURANCE pays usual, customary, and reasonable fees for a basic eyewear package. We actually have eyewear packages that are completely covered by these pure insurance programs which reimburse us a fair fee for our products and service. However, VISION BENEFIT PLANS are another story since they rarely pay in entirety for the eyewear and dictate where folks must purchase their eyewear from in order to receive the benefit offered.

The bottom line is anyone can offer a Vision Benefit plan but not everyone can offer Vision Insurance.

Kevin

I am sure that many of you, like me, are surprised to see the results of this poll thus far. I am shocked that over 41% of those responding do NOT accept third party insurance plans. I am one of that group. I am curious to know more about those that responded like I did.

Do you accept ANY type of payment from insurance companies?

What type of insurance climate is your shop located in? I am in a town where most...I really mean MOST...like more than 70% of the population belongs to an HMO.

How long have you NOT been accepting third party payment. In other words, was this a recent decision made or has this always been your policy?

What type of business are you? Optical shop with Ophthalmologist, Optometrist or, better yet, an optician doing it all on his/her own;) ?

Just curious...
the chick

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Hip Chick,
We are an optometrist's office, and we are participating providers for VSP and are non-participating providers for Medicare. We don't accept any other insurance.

If a patient has any other insurance, they must pay us upfront and we will fill out their form for them. Some don't like that idea and go elsewhere, but plenty seem satisfied to pay us upfront as long as they get reimbursed by their insurance.

This seems to work for us.

AMEN!! Good going to all you non insurance people. If I ever get to open my own dispensary I will definately not be accepting 3rd party. Yes it is ridiculous how you have to explain to the patient what coverage they have. Most have absolutely NO CLUE. Then BEFORE they even purchase they want to know exactly what they are going to pay. I like the fact that it was brought up about how much vision insurance actually pays. For that $480 that they could have saved they could have purchased some really great eyewear. I wish we could actually make the public see this. You are not kidding I wish I worked on those profit margins too. See they get away with it since most people don't understand insurance( and who could blame them? It is confusing as can be for the most part) all they "know" is they have vision insurance they don't even realize most aren't even worth having. Yes I hate all vision plans!!! Wish we didn't have to be bothered by them!!!

Steph

Steph:

I'm with ya' sister !

However, I was a big talker until the company down the street signed up on VSP. They have 5,300 employees, less than 400 yards from my front door !

I'm still a big talker, but now I have to take VSP.

Yeah. We ALL hate 3rd party, but stand up and refuse to accept the insurance of your towns biggest employer, and you might find yourself being one of those employees down the road.