3 Ways to Make Sure Your Ophthalmology Practice is Verifying Insurance Properly

By Byrd Evans on August 31, 2018

According to Modern Medicine Network, the time it takes your front desk staff to verify insurance costs the practice about $2.55. Compare that to the $10.5 billion in uncompensated care provided by practice physicians each year, as calculated by Health Affairs. Spending $2.55 per patient to confirm they have coverage and to increase the likelihood that you’ll get reimbursed for your services doesn’t seem like much. Let’s consider three ways to ensure your practice is verifying insurance properly.

  1. Verify Insurance Before Every Visit

Regardless of how many times you’ve seen a patient, verify insurance before each visit. Lives change quickly. People move jobs. Policies change. Patients simply stop paying their premiums. Here are three key impacts of verifying insurance before every visit.

  • You can accurately estimate revenue. Revenue cycle projections are critical to running an efficient office. Knowing how much the practice will get reimbursed through an insurance carrier prior to the service being provided allows you to project when those funds will come in and when the patient portion will be collected.
  • It’s a service to the patient. Think of insurance verification as part of your customer service strategy. Insurance policies are confusing and change frequently. Most patients are not sure exactly what’s covered and what they will owe. Verify coverage ahead of time and inform the patient of their portion. This allows them to plan ahead and work out a payment plan if necessary. One report found that 74% of satisfied patients paid their medical bills in full. What made them satisfied? Their satisfaction rating was based on the billing processes of the hospital. Of those that gave the billing process a top score, 82% would recommend the hospital, 95% would return to the same hospital and 74% paid their bill in full. Don’t doubt the impact of the billing process on customer service. The first step in making a good impression is informing the patient up front so they are not blindsided with a large medical bill later.
  • Verification protects you. Verifying insurance protects the practice in case claims get denied down the road. If you do not verify and the carrier denies a claim because the service is not covered, you basically lose that money. However, if you verify and are informed the service is covered, you can refer to that documentation if the carrier denies the claim later.
  1. Know the Difference Between Verification of Benefits Vs. Coverage

The advantages of verifying insurance at every visit will be negated if your front desk staff doesn’t understand the difference between verifying insurance coverage and verifying benefits. Verification of coverage is simply confirming the status of the patient. Is their policy active and paid? You are confirming that as long as premiums are paid, coverage will continue. However, for claims to be covered, the patient must not only be active, but the service or procedure performed must also be a benefit that is covered. Verification of benefits authenticates that the benefits you are about to provide are covered under the policy.

If your front desk staff verifies coverage, but not benefits, it’s likely that a service will be performed that will not be covered. The result is that patients will not be prepared for how much they owe. These misunderstandings often get blamed on the provider. One survey showed there’s plenty of blame to go around for rising health care costs and patients “put little blame on themselves. It appears they see healthcare problems as beyond their control.” Although patients should verify benefits themselves, they do often depend on the provider to interpret insurance coverage. When high bills surprise them, they often feel like there’s been a lapse on the provider’s part. Protect your practice and gain the trust of your patients by verifying coverage and benefits. Here are three ways practices are streamlining this process:

  • Insurance portals. Insurance carriers often have their own web portals that can be used to verify benefits and coverage. While more convenient than picking up the phone, the downside of these portals is that staff must learn each carrier’s platform and only one patient can be verified at a time.
  • Clearinghouse systems. Some practices are using clearinghouse systems that allow staff to learn just one platform that can verify insurance from a variety of carriers.
  • Outsourcing. Many practices have transitioned to outsourcing their verification process completely, giving all the clerical work to an outside agency.
  1. Handle Referrals Correctly and Understand Par Vs. Non-Par Physicians

Referrals are critical to acquiring new patients for ophthalmology practices. In fact, 78% of physicians say new patient referrals are “very” or “extremely” important. Ensure your new patients receive a good impression by verifying if they need a referral. When verifying patient insurance coverage, ask if a referral is needed. Conversely, when a referral comes in from another physician for a new patient, verify their insurance and contact the patient within 48 hours.

Your front staff must also understand the difference between being a participating (par) or non-participating (non-par) provider. This status has implications for both the practice and the patient. Par providers have a specific agreement outline of terms and conditions of participation. For example, each carrier may have a different definition of medical necessity. What the provider views as necessary may not be viewed as such by the carrier. Treating a patient without verifying medical necessity might result in higher bills for the patient and uncollected accounts for the provider. Practices must have an efficient utilization management strategy that obtains pre-certification and pre-authorization. Following the complete process is the only way to ensure patient quality and cost control. Utilization management involves developing a specific process that assesses the appropriateness of a healthcare service or procedure. The front desk staff at participating providers must consider their carrier agreements when verifying insurance benefits.

Being a non-par provider, however, doesn’t mean you are home free. It’s important to explain to the patient that you are a non-par provider and what that implies. Most likely their portion of the expenses will be higher. Being a non-par provider might also mean that a procedure is not covered at all. Non-par providers might accept Medicare, but they might not agree to take assignment in all cases. In other words, you do not accept Medicare’s approved amount as the full amount and the patient will get billed for the remainder. Transparency with the patient is key. Knowing that information up front will allow the patient to make an informed decision about their care and avoid uncollected accounts for the practice down the road.

In summary, front desk staff must:

  • Verify coverage
  • Verify benefits
  • Verify if a referral is needed
  • Understand if the provider is par or non-par and explain what that means to the patient

If the insurance verification process is bogging down your staff or if you are finding that errors or oversights are routinely being made, it may be time to consider outsourcing this process. Agnite Health LLC, an affiliate of Advantage Administration, Inc., can partner with your practice to enhance your customer service and boost your revenue stream through the implementation of specific processes to improve your verification process. Contact us to learn more about our options to help your practice grow.