by Randolph Brooks, O.D. You did a comprehensive eye exam last week, and the patient just came in to pick up his glasses and contact lenses. As he writes his check, he tells your
receptionist that he belongs to some vision plan in which you participate and wants to know if he's entitled to reimbursement. While she's rummaging through file cabinets trying to find information about that plan, the patient
you've seen several times for iritis calls to say she must switch doctors because she didn't realize you weren't on her HMO's panel. The whole time, the harried receptionist is silently cursing your insurance secretary, who won the
lottery last week and is now somewhere in the French Riviera.
OK, maybe your insurance secretary doesn't play the lottery. However, you still should have an organized way to keep information about the plans in which you
participate. And, you want more than one person to have access to this information when patients pose questions. If just one person can answer questions and she's out of the office, you or your other employees may have to deal with
patients who expect you to have the answers to their insurance questions. They judge your practice more on the experience they have with their third-party reimbursement than on the quality of your clinical skills. This, in turn,
creates more stress for your office. Also, if you don't keep track of the plans in which you participate and stay up to date with that plan's rules, you may wind up with delayed or even missed reimbursements.
However, these
three simple methods can be a winning ticket for keeping yourself, your staff and your patients informed.
1. Signs. Rather than litter your reception area with plaques and decals, hang one sign that lists those plans you accept.
This can be a simple typewritten sheet or a professional sign with removable letters that you can easily update.
Keep a copy of this list behind the reception area. Include the plans you participate in and those plans you
dropped or may join later.
If you recently dropped a plan that covers many of your patients, post a sign to let patients know you no longer participate in that plan. (Your receptionist should also mention this when patients first
schedule appointments.)
2. Quick-reference sheets. Keep a one- to four-page list that gives your staff important information about the plans in which you participate. Set the page up horizontally, with columns that describe:
• The name of the plan.
• What's covered. Does the MCO cover the so-called "routine" eye exam, and if so, how often? Or, does it cover medical eye care only?
• Referrals or authorizations. Can the patient self-refer? Or, does
he need pre-authorization from the plan or a referral from his primary care physician?
• Co-pays, deductibles or co-insurance. This information sometimes varies even within the same plan. Your staff often must read the
information directly off the patient's card, or call the plan. Even then, you have to wait for the explanation of payment or the payment itself to see if you billed the patient correctly.
• Additional notes. Perhaps the plan
covers eye exams more frequently if the patient already wears glasses. Or, there are other special rules. Write this information in the column, or fill this column in with footnotes and put the additional information at the end of
the list.
Store a copy of this list on your computer and have an employee update it regularly, especially when a plan changes (be sure to note the date of revision). Review them at staff meetings.
3. Full insurance binder. This
is necessary for your office to function efficiently. If your practice participates in many third-party plans, this binder could contain anywhere from 50-100 pages. Some of your largest plans may require their own separate binder.
This binder will contain all of the items on your quick-reference sheets—and much more. For each plan your binder should include:
• Copies of sample ID cards.
• Names and phone numbers. Include your provider-relations
representative (indicate if a specific rep is assigned to your office), the claims department, any claims representative with whom you have a rapport, and the claims supervisor.
• Sample claim forms. Include the mailing address for claims, too.
• The patient's co-pay, medical or vision coverage.
• Rules and procedures. Does the patient need a referral from his or her primary care physician or
pre-authorization from the plan? Specify that in the binder. Note any procedures, such as punctal plug insertion, that may require pre-authorization. Also include information about how to extend claims. Must the primary-care
physician extend referrals for patients who require long-term care, or can the claims department do this?
Make note of any special requirements. Can you file claims electronically or must you submit paper claims? How do you
appeal denied claims? Does the plan have any special procedure coding requirements other than those required in CPT-4? Also, does it require certain ICD-9 diagnoses to be matched with certain procedures or services?
As
with your quick-reference list, have an employee update this binder continuously and note the date of revision on each sheet. Insert bulletins the plan sends you whenever they contain pertinent information. The employee who
maintains this binder shouldn't be the only one who's familiar with its contents. Your office manager and receptionist should also know what's in it.
While you may have an employee who specializes in third-party issues, you want
to have a backup. These simple steps can keep you and your staff in the loop and able to answer patients' questions. They're also helpful if you do not have an insurance secretary.
Keep all this information accurate and
up-to-date. Let your patients know what plans you participate in and keep your office staff informed. Hopefully you will be able to avoid the nightmare patient who tells you all about his or her insurance coverage after the fact.
It may also help you avoid delayed payments and angry patients who leave your practice. Unless, of course, you went in on a winning lottery ticket and the only updated information you're concerned about is flights to the Riviera.
