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Thread: OOPS! I "forgot/didn't know" I have insurance!

  1. #1
    Eyes eastward... Uilleann's Avatar
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    OOPS! I "forgot/didn't know" I have insurance!

    I'm sure most of us have run in to this from time to time: Pt come in. Pt states they have no insurance and will be cash pay. Pt has exam. Pt purchases eyewear or contact materials.

    Time passes.

    Pt (or often pt's spouse/significant other) calls to inform us that WE billed them incorrectly, because they DO have vision insurance after all. Then they proceed to demand a refund for the difference.

    Obviously if work was required to be done with an ins. co. lab, they're stuck. But in the cases where it was a private lab (such as EyeMed for example), often OD's will simply offer the refund out of the sheer terror of loosing their patient.

    It seems to me that this would be a "live and learn" scenario for the pt, and that they should be on the hook for working with their now mysteriously present and active insurance company for reimbursement on their own. I'm curious to know how some of you may have handled situations like this in your own practices? Do you always make the refund? Do you tell them they're is nothing that can be done this time, but next time we'll all know better? Do you find an alternate middle ground?

  2. #2
    Master OptiBoarder
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    if that happens after the sale, i tell them to contact their insurance provider for a reimbursement form and offer to help them fill it out with all of the correct codes and stuff. especially weeks/months later, if its a couple of days we'll usually work with them, but otherwise thats the best we can do! :)
    "what i need is a strong drink and a peer group." ... Douglas Adams - Hitchikers Guide to the Galaxy

  3. #3
    Master OptiBoarder CCGREEN's Avatar
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    Hey as long as I have NO CONTRACT with that insurance company I feel its my call. When you have no contract with a insurance company then it is only a courtesy to the pt to file for them if you chose to do so. If the pt was a pain in the a$$ to work with and the sale was small I would be offering them the paper work to file for themselves since everything has been finalized.
    If they were pleasant and the sale was large and I would love to have them back in the office then I would try to accommodate them.
    Thats where I like NOT having contracts with insurance companys........I get to make the call.

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    Master OptiBoarder NCspecs's Avatar
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    Yeah, no, we don't play that game. You live, you learn, you file on your own. We have people who want us to change the dates on their bills. I have no trouble giving a firm "No, we do not commit insurance fraud." My bosses stand behind the staff 100% on this.
    "Strictly speaking, there are no enlightened beings; only enlightened activity." -Shunryu Suzuki

  5. #5
    What's up? drk's Avatar
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    Vision care companies feel like the providers are trash (expense) and the customer is king (income). They ALWAYS side with the "member". They will always lean on you to rebill and refund.

    If it's within a reasonable time frame (and I mean a day at the most), we will try to rebill/refund. But after about 24 hrs the frame is at the lab (and as mentioned, maybe not the plan's lab) and the job is underway.

    Becc is right: after that, they can submit for out-of-network benefits, and we'll be nice and help. The truth is, though, is that it's the patient's responsibility to provide vision care information before the service, and everyone knows that, even the patient.

  6. #6
    Master OptiBoarder
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    This ties in so well for the people who come in and ask "how much does my insurance cover?" To which I reply, "What kind of insurance do you have?" And then you get the surprised, blank stare and "I don't know". I swear I am half optician and half "Insurance Detective". I do it to keep the bosses happy but I would so much like to tell people to figure it out themselves and then let ME know. About 25% of the time, they don't even HAVE insurance for vision, or they DO but it's not attached to their major medical.

  7. #7
    OptiWizard anthonyf1509's Avatar
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    If you or your office accepts insurance, then being fluent in these areas helps immensely.after the fact, then they'll get the reimbursement. No refunds. However, offering to "sweeten the deal" for another eligible family member in future helps too. Dr K is correct, the client/insurance company relationship is king. But the client is in your office and it's fairly easy to lay blame on the insurance company for poor notification. You never want the patient to feel responsible for a mistake they made. Even if its as simple as they do not know wtf is going on in their own lives!

  8. #8
    Master OptiBoarder
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    Even though it is a PITA I have (if within a few days or weeks) reversed the sale and billed the insurance as a courtesy to the patient. If it's been months (once nearly a year) then I offer to fill out a reimbursement form for them but don't guarantee payment. I don't like reversing the sale but most people are fairly nice about asking and realize they should have known beforehand so I will do it for them. It doesn't help my business to get on my high horse too much.

  9. #9
    Master OptiBoarder AngeHamm's Avatar
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    Quote Originally Posted by NCspecs View Post
    Yeah, no, we don't play that game. You live, you learn, you file on your own. We have people who want us to change the dates on their bills. I have no trouble giving a firm "No, we do not commit insurance fraud." My bosses stand behind the staff 100% on this.
    Agreed 100%. "We cannot change the filing status of your order because that constitutes insurance fraud." I say it with a smile, but I'm not afraid to reference the big I.F. I've found it to be a scary enough term that it often ends the conversation then and there.

  10. #10
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    Had that situation arise once before. We did a Seiko Surmount lens for a patient that "didn't have insurance". A few weeks later, patient came in saying that he forgot and had VBA. We take VBA but VBA doesn't accept the Seiko Surmount. They said they would reimburse the patient a sum that was far less than what he paid. We told the patient that and that was that. Patient realized he had made a mistake. Still came back to us for his next exam.

    We have also had patients come in weeks after picking up their glasses who now say they have insurance. If it is insurance we take, then we go back, refigure and refund them the difference and then we call the insurance, tell them what happened and the insurance then pays us. Never had a problem. However, they must have had the insurance on the day they ordered the glasses. We will NEVER change any dates for any reason.

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