After more than 35 years in the optical business, I have been forced to learn to work with an insurance plan. I started out with a "biggie" and my friends were amazed that anyone could teach this "old dog" any new tricks, but I persevered. It took me a few months to successfully and confidently master the maze of co-pays, allowances and price sheets.

I started thinking...why and how does a practitioner decide which plans to honor?

The logical way to start looking for answers is to find an expert. I found Lindsey Hammond at Gilbert Eyecare in Norfolk, VA. She's the insurance specialist for this two location practice that has changed its identity from boutique optical retail to boutique optometric practice with great success.

I asked Lindsey for a few basic tips on selecting which insurance plans to accept. These are her top three.

1. Review the reimbursement schedule. How many patients will need to be seen to maintain a realistic income stream? Can your practice afford to lose exam time normally given to full pay patients so that your insured patients can be seen? Are there limits on what lens, frame and contact lens products you can offer?
   

2. How many "lives" are covered in your area? Insurance providers love to talk about the number of "lives" they cover. While the number might be really impressive, if they're not in your area it won't really matter. Who are the employer groups who are currently utilizing the plan? How many other practices are accepting the plan in your area? This might be a topic of discussion among your peers. Have you had calls asking about specific plans? Have you had to turn away potential patients or will you risk losing current patients because you are not a provider?
   

3. Can your office file claims electronically? One of the most important issues to consider is the length of time between the office visit, filing the claim and receiving payment from the provider. Electronic filing has cut that waiting time significantly over the past few years. More and more professional offices are utilizing state-of-the-art practice management software that enables claims to be filed and tracked through the entire process. Gone are the days of waiting for the check that never seems to come or a notice saying that the claim was lost or mailed to the wrong address.

If your practice is not currently using practice management software to integrate every function from appointment to exam, from Rx to insurance claim, it's time to get started. You could be losing money, time and patients.

I was also curious about what needs to happen so that claims are paid promptly. Lindsey's number one rule is make sure all the information is correct before you file. This requires that there be open and easy communication between the front desk, the practitioners (Ophthalmologist, Optometrist and Optician) and the insurance office. This is another area where integrated practice management software is a key ingredient for success.

Claims should be filed quickly and tracked either with the software you're using or even a simple spreadsheet. Lindsey advises to check claims and payments at 30 days after filing electronically and 45 days if a paper claim is filed. That means if you're filing every day, you're also checking every day. She also tries to work with the same person at each plan office if possible. These more "personal" relationships can be invaluable in resolving claims/payment issues.

Lindsey seems to have this part of the practice well under control. Now let's take a look at what's happening on the other side of the door...the front desk, the dispensary and the exam room.

Most plans require that their members be treated in the same manner as a fee-for-service patient. No limited number of available appointments, no "insurance only" scheduling days. This means that your exam will become more concise and compact. The scheduling will become more time sensitive and the tolerance for late or missed appointments will be less flexible. Some practices have instituted a fee for missed appointments, a tactic that many medical practices have used for years. Unfilled exam slots are more expensive when you're already accepting reduced exam fees and providing deeply discounted eyewear and contact lenses. Confirming appointments with a nice and friendly reminder for your patients is now a critical task for your front desk personnel.

Your choice of labs and spectacle lenses, frames and contact lenses are all affected by your choice of insurance plans. You must learn to tailor your frame selection to address the requirements of the plans you choose to accept yet still appeal to your non-insurance fee-for-service patients. You will need to evaluate the profitability of every product and service you offer. That's a pretty wide expanse of merchandise to evaluate. Your most valuable resources should be your frame and lens reps and your lab reps. They know what's being used successfully in your market and with your plans. Make them your partners.

All of these ideas are old news to the newest generation of ECP's, but present a pretty steep learning curve for us "old dogs."