Insurance and Responsiblity

[Joann Raytar]

Who is responsible for tracking patients insurance benefits the provider or the patient? Should the patient be responsible for knowing if they have routine eye exam and/or hardware coverage and if it is currently valid or should providers chase that information down for them?

[Jackie L]

A little bit of both.

I find that some of our 'Senior" customers/patients need a bit of help understanding Medicare or Medicaid and other 3rd party or secondary insurance. It is a courtesy to track down the info.

The others.........well, I guess they are on their own.

[Joann Raytar]

Right now we verify benefits when folks book their appointments. It is very time consuming but works better than tracking things down on the fly. It just gets nerve racking when you have to explain to someone that they aren't eligble for one reason or another. Some folks get down right insistent about being covered. Many folks won't call their insurance companies on their own and we keep getting caught in the middle.

[Alan W]

I have yet to find one insurance company that has published a phone number and sent out a notice that says:

"Before you visit or plan to visit a provider, plase call this number to see if you are elligible. Providers are not responsible for the status of your insurance coverage"

Why?
Because they know it is cheaper to dump that responsibility on the provider than it s to ramp up to handle the volume of calls they would receive.

They are just there to make the money.

[Diane]

We used to get tons of calls from folks that wanted us to call for them BEFORE they came in for the visit, which we were happy to do, because we are service oriented. Then we found out that a lot of them call everyone in town to do the same thing, and EACH of us was spending the same amount of time to find out the same thing for each potential patient. SOOOOOO, we now tell them that there is a number on their card that they can call themselves, and if they ask us to call for them, we tell them to come into the office with their cards and WAIT while we call for them, and explain the time it takes to verify coverage. We've actually explained that time to them and they understand it. We still feel that we are service oriented, just don't want to be abused.

Who is managed care really good for anyway?

:hammer:

Diane

[Tammy]

Jo,

I agree with everyone, it is very time comsuming, on the commercial claims we always get payment up front, for anything that is not considered standard (trans, tint, sc, progressive, frame overage, etc).

In the case of the senior citizens, we do hold them by the hand and explain all in detail, besides with Adminastar (Medicare) the patient must sign a waiver with a description and cost of everything that is not covered.

Billing is always an option for the office unless you are par, and we do tell the patients we are doing it as a courtesy, which makes us look very good in their eyes, thats why they are returning year after year.

OPTION is the key word for non par claims. Hope this helped.

Tammy

[rfish777]

Jo in Rochester New York we are governed by two large HMO's.
One of the HMO's is Blue Cross where they provide ( If you sign the agreement) a 20% discount (which comes out of your pocket)
and $60.00 towards glasses or contacts. The benefit can be used
only once every two years. The other HMO does the same thing.
These two cover almost 90% of the population in and around Rochester. I said all that to say, there is not a day that goes by
when at least 5 people will come into our office and say I don't know what coverage I have. We then have to call up the HMO
and find out 1. If they are covered 2. Are they just covered for
eye exam or eye exam and glasses. This is all time consuming and
basically a big pain in the neck. But with out these two HMO's most retailers would dry up.
:(

[chip anderson]

With most but not all insurance companies we deal with (we are an independent optical dispensary) there seems to be a conspiracy to avoid paying claims, especially for artificial eyes. Blue Cross/Blue Shield will find every excuse to deny claims, they will give you advise on why a claim was rejected and reject it for following thier advise. I have even had some of the lower eschelon employees say that they automaticly reject claims until the third submission.

I used to know an ophthalmologist who had his patient go to the bank with him and make a loan before he would do surgery. He always told me to get my money up front. I thought he was very callous, now I think he was just astute.

Try to stay away from plans and get as much up front as you can. Let the patient file and try to get payment after he has paid you.

Chip

P.S. I have even on a few occasions discussed this with a few doctors who had similar difficulties concidering a class action suit.
I also knew one doctor that for a 12% fee had a service that tranlated his billings from plain English to insuranceeze and harrased the insurance companies until they paid. This would be a great business if you had a good client lists of surgeons, just
8 of them and you would be making as much as they do.

[LO1007]

I was in an office today that had a sign posted that said,
"The patient is responsible for obtaining any referrals or information regarding your vision care insurance coverage.
We appreciate your cooperation in this matter. "

I would hope it works to some degree and they probably tell the patient that when they call. And I bet in some cases they call for them also, but this at least gives the patient some responsibility for knowing their own insurance coverage.