Managed Care

Why & How to Pre-Certify Patient Insurance

By April L. Jasper, OD, FAAO


Obtaining patient insurance information when they make their appointment, and then establishing an in-office protocol for verifying and processing it, is key to a smooth office flow and positive patient experience.
Create Pre-Certification Process

When patients call for appointments, our staff asks the reason for their visit. Then, we collect their insurance information for both medical and vision, as well as the name of the person on the card and any other identifying information, along with the name and identifying information of the person whom the insurance is under. At least two people in the office should be able to verify insurance even, though, in a one-doctor practice, like mine, that job responsibility is typically assigned to one person. The information that is uncovered should then be noted in the appropriate place in the patient’s record so that it is visible to the person in charge of collecting the co-pays on the day of the patient’s visit.

Typically, in our office, the person who verifies the insurance information is not the same person who reviews all of the information when preparing for the day’s patients. It is always good to have a check and balance system to be certain all the necessary information has been collected. In a one-doctor practice with 70 percent insurance volume, this and the reconciliation of EOBs, can be a full-time job for one person. Another task this person can perform if time permits is to send out statements, resubmit insurance claims that need correction and answer the phone when needed.

Re-Verify Once in Office

Most insurance plans require you to copy the patient’s card and do your best to verify the person you are caring for is the cardholder. We ask for a driver’s license if applicable and also take every patient’s photo at the front desk to enter into the demographics section of our EHR.

We tell the patient they can check their vision plan coverage online before the visit. When the patient is in the office, we help them select frames and lenses and show them from the insurance print-out exactly what the insurance contribution is. This allows them to see that the numbers are fixed and not manipulated by us in any way.

Educate Patients

We are very specific with patients regarding insurance coverage for professional fees and services, and review everything with them before the patient sees the doctor. We review the benefits for eyewear with the patient in the optical when they select their eyewear. In today’s current healthcare climate, patients do not like surprises. Patients typically expect insurance to cover more than it does, and when they are disappointed with their insurance contribution toward their purchase, the doctor can often be the recipient of the blame if the fees are not explained first.

Alert Patient of Lapsed Insurance

The most important thing in cases in which the patient’s insurance has lapsed since the time they made the appointment, is to let the patient know before any services are rendered. We will always apologize for the inconvenience or misunderstanding and give the patient the option of re-scheduling until they can work things out with the insurance company. What we try never to do is provide services before payment is reviewed, and in most cases, paid.

Let Patients Know of Services Not Covered

We let patients know about non-covered services as soon as we know in an effort to avoid unhappy patients. Lack of communication is the most common reason for loss of trust between the patient and doctor. It doesn’t matter whose fault it is; what matters is what the patient’s perception is.

Manage Insurance-Related Conflict

We have had times when patients were told by a person at their job that their benefits were more than what they were. They didn’t verify this information with their insurance plan, so when we told them of their benefits, they were upset. What we try to always remember is that the patient is not upset with us; they are simply unhappy with the situation. This is another reason why it is better to have these conversations before services are rendered so it doesn’t interfere with the patient/physician relationship.

Drop Unprofitable Plans, But Don’t Abandon Patients

We have dropped several insurance plans over the past 13 years based on our ability to cover our expenses with the reimbursement they offer. Every plan has in the contract what the requirements are to drop a plan, and it is typically 90-days notice that must be given to the insurance plan. You are able in many cases to give the patients that were on the plan you dropped a small discount to stay with you if your practice chooses to do so. The main thing to remember in the case of dropping a plan is to never “abandon the patient.” There are specific laws regarding patient abandonment that must be followed in each state.

April Jasper, OD, FAAO, is the owner of Advanced Eyecare Specialists in West Palm Beach, Fla., and a Vision Source Administrator. To reach her:


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