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
I asked Lindsey for a few basic tips on selecting which
insurance plans to accept. These are her top three.
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?
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
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
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
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
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
My advice? Don't panic. Take a deep breath and begin the
same kind of business analysis that made you successful the
first time around. Lindsey's advice? Find the most
knowledgeable insurance specialist you can and let him or
her help you succeed.