How To Get Paid More, The First Time

A practice’s revenue cycle is made up of several components, all of which are important. Establishing a solid approach to revenue cycle management is essential because having a steady cash flow from insurance companies and patients alike is imperative to ensuring financial viability.

One of the biggest misconceptions many eye care practices have is not realizing that patients — not insurance — are their primary source of income. For most practices, patient payments account for roughly 60% of revenue. Therefore, collecting from the patient the amount for which they are responsible while they are still in your office is a key driver to timely accounts receivable.  Why allow them to leave the practice without paying their portion of the visit! Many practices let this happen because they find it challenging to determine the patient’s out of pocket responsibility on the spot. Read on to avoid that pitfall.

Return On Investment

Many offices perceive that it’s not worthwhile to have their staff devote time to proactively checking insurance benefits. Amid the day-to-day hustle and bustle, it can be challenging to see how this process can provide a return on investment (ROI), however, careful review demonstrates that the ROI is there.

Checking benefits before or during a patient visit:

• Before or day of visit: Staff members spend a few minutes to research and document the details of a patient’s insurance benefits and determine the patient’s estimated out-of-pocket cost. This amount is collected before they leave the office.
• Following the visit: The claim is submitted to insurance, which is typically paid within four weeks. There is a good chance that there will be little to no balance remaining for your patient, or a small refund might be due. 
• You have collected most, if not all, payment within 4 weeks of the date of service.

Not checking benefits before or during a patient visit: 

• Before of day of visit: N/A
• Following the visit: The claim is submitted to insurance. Only after the insurance pays (typically within 4 weeks), you send the patient a bill for their portion of the charges, then wait another 30+ days for the patient to pay. It may even become necessary to send a second or third bill before payment is received. 
  
  Mailing statements can cost a practice between $5 and $25 per statement. Statistically speaking, when a patient walks out the door without paying their bill, the chance of recovering that money from your patient significantly decreases!
• You are waiting 8-16 weeks – or more – to collect the full amount due AND you have incurred additional costs for generating multiple statements, following up with patients, postage, and possible collection agency fees. 

As the above comparison confirms, the small up-front investment in checking patient benefits prior to their visit directly correlates to receiving payment dramatically earlier.

Insurance Verification

One of the first things PECAA’s Billing and Coding advisors recommend is that practices check insurance benefits prior to seeing patients, approximately three days prior to the scheduled visit. You may wonder how checking insurance benefits in advance is going to help collect patient balances prior to the patient leaving the office. The advantages of checking insurance verification prior to a patient visit are as follows:

Confirms:  

• Active insurance coverage
• Correct patient/subscriber demographic information for insurance claim submission
• In- or out-of-network status
• Primary/secondary payor status
• Covered benefits, including frequency and dollar maximums for frames and/or contact lenses

Reveals amounts owed by the patient, if applicable, for:

• Copayments
• Deductibles
• Coinsurance

There are various ways to check insurance benefits for patients. In the past, the only way to check insurance benefits was by phone, which can be time consuming — fortunately, there are now a variety of methods to confirm plan details, which makes for an efficient process, including:

Online Verification

Nearly all payors have website portals for providers to check patient insurance coverage. Websites/provider portals generally display all benefits listed above — some even go into detail regarding procedure and/or diagnosis codes to be used and other claims processing tips for that patient’s plan.

Clearinghouse

Many clearinghouses also offer insurance verification for your patients, sometimes for a fee. Additionally, PECAA has several vendor partners who offer these services. While using a clearinghouse can be more convenient than checking multiple websites, some clearinghouses provide fewer details than if you were to look on the payer’s web portal. Clearinghouses may not give specifics for codes, and some don’t give co-pay, deductible, co-insurance or in/out of network details — but you can find out if the patient’s ID number is correct and if the patient has active coverage.

Phone

The least favored way of checking benefits — mainly because it is time consuming — is telephone. While this is sometimes necessary, we recommend this as a last resort for insurance verification. Why? It takes time, and time is money. If you need to contact an insurance carrier by phone, be as specific as possible with the representative to ensure that you are getting the most accurate information as possible.

Recommended medical plan questions include:

• Is the patient’s plan in network with our provider/office?
  • If no: does the patient have out of network benefits?
• Are you the primary insurance (*specifically important if the patient is Medicare eligible)? 
• Is this an HMO plan? 
• Does this plan require a referral or prior authorization?
• What is the co-pay amount for an office visit at your practice?
• What is the patient deductible, out of pocket maximums, co-pays, co-insurance?
• What has been satisfied? 
• Are diagnostic testing/labs applied towards the patient deductible?

Recommended vision plan questions include:

• What is routine vision exam benefit coverage, and is there a copay?
• Is there a separate hardware benefit, or is the exam and hardware combined?
• Is that hardware a flat amount or line-item coverage? If line item (frame, lens, lens treatments), what is the allowance per item? 
• Is there an allowance for contact lens services, if so, do they come out of the hardware allowance? 
• What is the exam and hardware renewal period, and are they currently available?

*Note: Some plans have pediatric benefits for patients under 18 years of age and benefits may be different than a person 18 or older, on the same plan.

Regardless of which way your office chooses to check insurance benefits, the act of doing so will allow you to provide your patients with their out-of-pocket expense information prior to the visit. If insurance is estimating a high out of pocket expense, you will have the ability to give your patient advance notice — this can give them the choice to reschedule, cancel or accept that the money will be due at the time of service — ultimately lowering your outstanding patient balances and increasing patient satisfaction.

It is important to remember that the benefit information you are obtaining from the insurance company is NEVER guaranteed — it is always an estimate. Emphasizing to your patients – both verbally and in writing - that the amount they are being charged is based on the estimated out-of-pocket cost will go over more smoothly than them thinking their $40 copay was all that was due only to be billed an additional amount later. Another important thing to keep in mind is that you may not always get accurate information — perhaps the insurance company’s website wasn’t updated or there was a new representative that didn’t know how to interpret the benefits. Errors can be made with insurance verification, which is why emphasizing that the amount charged is merely an estimate is crucial when speaking with your patients about their benefits.

Want Assistance From PECAA’s Billing Advisors?

PECAA’s Billing and Coding advisors can provide efficient and effective tips, including insurance verification templates and a Billing and Coding Certification Program.  If you are a PECAA Max member, contact a Billing and Coding Advisor today! Not a PECAA Member? Contact us to learn how PECAA can help your practice thrive.