Progressive Focus©

Progressive Focus© Newsletter


Volume 3, Number 4 Winter, 2002
Helping You Manage the Expectations of Managed Vision Care

In This Issue:

Collecting The Fees You've Earned And Deserve

Steps you can take to reduce or eliminate unpleasant payment responsibility questions at the checkout desk and with contracted insurance companies


To be prepared for war is one of the most effectual means of preserving peace.

George Washington
First annual address to Congress
January 8,1790

You work long, hard hours caring for your managed care patients' visual needs. And at the same time you take care to perform to the terms of your third party provider agreements.

In exchange for that care and attention to detail you rightfully expect to be paid in full and in a timely manner. So it's frustrating and irritating when a patient fails to tell your staff about insurance coverage prior to receiving services and then raises the roof when she's asked for payment in full. Or a patient refuses to pay for an exam and eyewear, claiming your staff never told him that your office doesn't participate with his vision plan. Or the patient pays in full but then a week later gives you insurance forms and wants you to refund all payments and bill the insurance.

Or, perhaps, you provide services after a third party payer authorizes and confirms benefits and eligibility. Yet, despite the fact that your staff has jumped through all the right administrative hoops, the payer then retroactively denies the claim or takes back money from future payments by claiming its database was in error when eligibility was confirmed. It advises you to seek recovery from the patient (who by now might be long gone).

In this issue of Progressive Focus© I'll offer some suggestions on ways to preclude problems such as these and reduce hassles collecting your fees.

Being proactive with patients

It should come as no surprise that a majority of problems directly related to questions of insurance coverage and financial responsibility can be prevented by attention to detail prior to the office visit. Unless the patient is intentionally deceptive, there's hardly a reason why you should be unaware of any insurance coverage that may be in place and who is responsible for what.

When the appointment is scheduled

Obviously your first opportunity to get it right is when the patient calls for an appointment. Staff should be able to extract most if not all of the necessary information while speaking with the patient. Here are some suggestions from optometric practices around the country.

1)   "When patients call for an appointment we're certain to ask if they have any vision care insurance. We make it very clear in that conversation that if there is insurance that will pay any part of the exam and/or eyewear that we'll need to confirm benefits and eligibility prior to the visit. And we tell each patient that if we are unable to confirm benefits and eligibility prior to the visit they'll be responsible for payment in full.

"So far this firm but polite prompting has helped us tremendously. While it requires a bit more work at the front-end, that's more than outweighed by the reduced hassles at checkout."

Another practice does much the same thing for its patients but takes the process a step farther.

2)   "We've actually created a script that the appointment staff uses on each call. If a patient has insurance that we accept we tell her that we'll call the insurance company to double-check the information. Then we always call the patient back to verify with her the available benefits (e.g., exam is available with $10 copay; eyewear lenses available this year with $20 copay; no frame benefit this year). By going through these steps there should be no surprises at checkout when we ask for settlement of the copayments, non-covered services, and any upgrades.

"If we can't confirm eligibility or benefits, or if we're not a provider for the patient's plan, then we let the patient know before the day of the appointment that we'll be happy to assist her with an itemized bill showing that she's paid in full. But we make it clear that it's the patient's responsibility to pay us first and then to submit for reimbursement."

At the reception window

Though not the preferred solution just discussed, your second opportunity to get it right is when the patient presents at the reception window. Here are more suggestions from your colleagues.

3)   "Each time patients visit our office we hand them a sheet on which they can update demographic information. One of the informational items we request asks the method of payment, and we give several options including cash, check, credit card, office gift (promotional) certificate, and insurance. If a patient checks the insurance box then there is a line for them to indicate the name of the company.

"If we've not previously confirmed insurance eligibility then at that point (before seeing the patient) we'll call the insurer to confirm. If we cannot confirm we tell the patient that they can either pay in full and submit for reimbursement, or they can reschedule once we're able to confirm eligibility and benefits.

"We know that this second option is not one they want to hear, so we try to make it a little less irritating by assuring the patients that we'll do all the work and we're happy to call them to reschedule a convenient time.

"Obviously we don't like turning away anyone from the reception window if they have an appointment. But if we did not get the information when the appointment was made, and if at the time of the appointment we still can't verify insurance coverage, then we've made the decision not to provide services. Been burned too many times and we've learned our lesson."

A fourth practice added:

4)   "Sometimes there's confusion as to which insurance plans we accept. To reduce the chances of misunderstanding our office has posted a sign at the reception desk. That sign lists the insurance plans in which we participate, and states that patients covered by any other insurance will have to pay in full and submit their receipts for reimbursement.

"The sign has been particularly helpful in those instances where a patient comes back to pick up glasses or contact lenses and only then reveals they have vision insurance from a plan in which we don't participate.

"The one downside to this method of notification is that we have to change the sign each time we add or drop an insurance plan. But that doesn't happen all that often, and the cost of a sign is small in comparison to the headaches avoided for the staff."

And yet another practice added this comment.

5)   "In addition to everything else staff does to pre-authorize benefits, verify eligibility, and confirm this information to the patient, we still have each patient sign a statement acknowledging that he or she is responsible for any amounts not covered by the insurance. Obviously we don't balance-bill the patient for the difference between our U&C and the amount paid by the insurance for covered services, but we do insist that the patient acknowledge responsibility for all allowed amounts over and above what the insurance pays."

Special concerns for Medicare patients

You and staff know that refractions and certain eyewear services are not covered by Medicare. Those are statutory exclusions. However, you may wish to provide other services to Medicare patients that also are, or might not be covered. Unfortunately, many if not most of these patients may not understand that Medicare may refuse to pay for such services.

Optometric practices can preclude misunderstandings with an ABN (Advanced Beneficiary Notice).

The ABN is a form that you'd use when you suspect or know that Medicare will not cover certain of the services you are about to provide. It's an informed consent document, and is presented to the patient prior to services. When read, signed, and understood, the ABN is the patient's acknowledgment that he or she will be responsible for payment if Medicare does not pay.


You can download the newest version of the ABN (in English and Spanish) from the following URL:

Being proactive with third party payers
Claims denied after eligibility and benefits are confirmed and authorized

I'd suspect that you've been through this frustrating scenario more than once.

Patient Smith calls the office and makes an appointment. He states that he's covered by the XYZ vision plan. Your staff verifies with the plan that he's eligible for the anticipated date of service. Further, staff verifies that he's entitled to an exam with $10 copay, plus frames and lenses with a $20 copay.

Smith presents as scheduled, you do the exam, and he gets a pair of eye glasses. He pays the copays plus plan-specified amounts for non-covered upgrades.

Your staff submits a meticulously completed electronic claim for exam and hardware. Not long thereafter you receive payment and deposit the check. And all seems well.

Then it hits the fan...

Many months later the vision plan sends you notice that it is now denying the claim you filed for patient Smith. The letter states that Smith was incorrectly confirmed as eligible for the date of service. Further, the letter states that the vision plan only recently realized that its database was in error and, therefore, it has deducted the payments for the exam and glasses from the current check (or, perhaps, it asks you to refund the money to the vision plan).

Though the letter apologizes for the error, it states that the plan is not financially liable for Smith's services; he is responsible. The plan suggests you contact the patient and attempt to recover the funds that it has now deducted.

The same scenario may have happened to you with an HMO for whose patients you're providing medical eyecare. Perhaps you were authorized to provide and were paid for services to treat GPC. Then, months or even years later, the HMO takes back the money and you're left holding the bag.

At that point what realistic hope do you have of getting the money from the patient or a different insurer? None, obviously, and that's the reason why it's so important to take steps that will reduce a third party payer's ability to create retroactive havoc with your finances.


I think the necessity of being ready increases. Look to it.

Abraham Lincoln
Letter to Pennsylvania Governor Andrew Curtin
April 8, 1861

Sometimes you have to play hardball

If you allow a third party payer the ability to unilaterally decide when it's going to retroactively deny claims and take back money, you've now opened a huge Pandora's Box. Payers will deny responsibility for the accuracy of their databases and will put the collateral financial fallout on your shoulders – the optometrist who provided care in good faith and only after staff followed all plan-mandated protocols.

But why should the financial damage resulting from the plan's inaccuracies fall on you? The reason is simple; you allow it to happen by signing contracts that don't prevent or at least significantly limit such outrageous conduct.

Get it in writing

Put simply, you must ask each third party payer to amend its provider agreement to stop unilateral, retroactive denials and change the protocols by which retroactive adjustments can be made. The payers won't like this one bit, and they'll try to blow you off with that tired old retort: "It's our standard contract. That's non-negotiable."

And that's nothing more than the payer trying to throw its weight around to scare you into accepting the unacceptable. You must not fall for that "standard contract" nonsense.

Only federal and/or state-mandated language is non-negotiable. Everything else should be open for discussion. But you may feel it's a hopeless effort to ask a national vision plan or a local HMO to make changes. Still, if you don't try to make changes, they certainly won't volunteer them.

And if you ask and if you're refused, then what is that payer saying? In so many words simply that: "We reserve the right to deny all responsibility for the inaccuracy of our databases and, further, it's not our problem that you have suffered financially as a result of following all proper protocols and relying on our data to provide services to our Members. Don't like it? Tough!"

Think about that. If a payer refuses to be responsible for its data and tells you to go chase the patient while it takes back your money and suffers no adverse impact from its errors, is that a plan you need? I suggest the answer may be no. And if it happens to you once is it likely to happen again (and again)? I suggest the answer is likely yes. Is that how contracting partners are supposed to treat each other?

So you need to address the following to your third party payers when negotiating new contracts or renegotiating existing ones. These hints apply to both vision plans (exams and eyewear) and to medical eyecare plans.

The core issues to pose

These are the core retroactivity issues you'll need to pose to payers. Ask your attorney to put the concepts into proper legal language.

State law will vary, but at a minimum here's what you want to see added to each contract.

Notice  The plan should have the right to ask for an adjustment of alleged over- or improper payments. But you should also have the right to request an adjustment for what you believe are under payments.

Window of Opportunity  Each side should have a reasonable but limited period of time following an alleged over- or underpayment in which to inform the other party. 90 days after the date a claim is paid or denied is probably sufficient to file a notice seeking adjustment. After that, payments should be considered final. In no case should a payer have unlimited time to go back into old claims history.

Collaboration  The parties should agree to work together to document and resolve any disputed amounts.

Reconciliation  Both sides should agree that once any disputed amount is substantiated, payment will be made to the other party within a defined time period (certainly no more than 30 days).


To always be ready for war, said Mentor, is the surest way to avoid it.

Télémaque (1669)
François de Salignac de la Mothe Fénelon

Education is what you get when you read the fine print.

Experience is what you get when you don't.

Copyright © 2003-2007, Gil Weber, MBA. No part of this newsletter may be reproduced or distributed in any form whatsoever without the author’s prior written authorization.

These materials are intended to provide useful information about the subject matter covered. The author believes that the information is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation of the materials are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any type are disclaimed.

The materials are not intended as legal advice, nor is the author engaged in rendering legal services. The materials are not intended as a replacement for individual legal or professional advice. Information contained herein is presented only for illustrative purposes, and it should not be used to establish any fees or fee schedules, nor is it intended and it should not be construed as encouraging any user of the materials to take any actions that would violate any state or federal antitrust laws, tax laws, or Medicare or Medicaid laws.

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