Guest Post: Medical Insurance Verification Action Plan

Posted by Madhu Singh on Thu, Apr 09, 2020 @ 08:04 AM

Have you ever discussed a medical insurance deductible with a patient and THEIR deductible is YOUR fault? Or has the patient ever been surprised that their co-pay was $45 at the checkout? These are telltale signs that you have an opportunity to educate your patients on how their medical insurance can cover their eye health conditions.

Most patients do not understand their insurance coverage, especially as it relates to medical eye care, and therefore do not use their insurance to its fullest. When you provide medical eye care, the patient is more loyal than the “retail only” patient. In order to build a lasting relationship, patients should know that optometrists are qualified to provide medical eye care. 

Jerry Godwin from OMS shows us how to verify insurance before patients arrive at your practice so that you don't miss out on revenue. We've included his action plan below, but you can read more information on his website.

8 Step Insurance Verification Action Plan

Insurance Verification

  1. If possible, try to obtain the both the patient’s insurance ID number and their social security number.

This information provides all the data you need on the insured to collect the benefit information. Carriers often issue new ID numbers for patients. Your patient may not be aware of the change and could be carrying an old ID card. Having the SSN provides you the ability to access the patient’s benefits despite having an incorrect ID number.

  1. Confirm that you are quoted correct benefits.

Most errors occur when out-of-network (OON) providers are quoted in-network rates. OON benefits are usually quoted in percentages. If you are OON and the representative quotes a co-pay, stop and confirm you are receiving OON benefits. Same holds true with verifying the deductible(s).

  1. Find out if the plan you are verifying is a true insurance plan or if the carrier is acting as the Third-Party Administrator (TPN).

Many health plans are not true insurance plans, rather they are self-insured plans managed by an insurance company. It is common for mistakes to occur when benefits are being quoted for these plans. The companies funding the plans write their own benefits package and can write in coverage not normally covered by the insurance company. This can create issues for the phone rep you are speaking with in that they are not fully familiar with the plan you are calling on as it is different than their own plan.

  1. Always get the following information and document it from your call: representatives name, call reference number, date and time of call.

Never count on the call being recorded or the fact the provider rep is quoting you accurate benefit information. Our experience has proven that the insurance carrier will find documentation of a call only when it benefits THEIR position, not yours. An appeal for benefits or a claim depends on the accurate documentation of benefits, who you spoke with, the call reference number and the date/time of the call. Also, if you do not feel confident in the information the representative is providing, ask for a Supervisor and have the Supervisor confirm the information you have been given.

  1. Find out the filing time for a claim.

There are timely filing limits for the insurance claim. Commercial payers are 90 days, some are 120 days and Medicare is 1 year from date of claim filing. Know what these are to avoid non-payment for timely filing.

  1. Ask about all of the procedure codes covered, include questions about routine vision benefits.

It is important to ask for as much information as you can. Document the patients coverage for all of the diagnostic equipment you have in the office, ask about routine vision coverage (exam & materials) and the last date used, and ask for other related surgical codes (foreign body removal, punctal plugs, amniotic membrane, etc.) to ensure you have the full scope of benefits.

  1. Once you have verified by phone, you do not need to call again.

Once you have verified the patients benefits by phone, then you do not need to call them again within the calendar year (for commercial plans). The coverage will be the same for the procedure codes. All you have to do is electronically verify benefits to see the change in their deductible to know what to collect. The only exception to not needing to call is if you are wanting to verify the routine vision benefit. You have to call to see if the routine benefit is still available.  In most cases this information is not available online. Specifically ask if the patient has utilized their benefit for the calendar year.

  1. There are no short cuts to accurate information.

Unfortunately there are no shortcuts when verifying medical insurance benefits. If you have ever placed a call to verify coverage or benefits, and have been placed on hold, you should be familiar with the disclaimer “Verification of benefits is not a guarantee of payment.” Hold the reps accountable. If the rep is uncertain, call back and re-verify benefits to ensure accuracy. Be specific in what you are asking!


There's still a lot more to know about setting up your claims process for success. Follow our guide below.

Download Your Guide

Tags: Practice Efficiency, Electronic Claim Filing

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