The Benefits of Medical Insurance Verification

By | January 26, 2016

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 care conditions.

How is it that patients do not understand what their medical benefits are? Most patients do not understand their insurance coverage, especially as it relates to medical eye care. Could it be they do not realize what “full scope” Optometry can provide? This is most likely the case. Patients do not understand Optometrists are qualified to provide medical eye care leading to a lasting patient relationship. When you provide medical eye care, the patient is more loyal than the “retail only” patient. Medical eye care galvanizes the doctor patient relationship.

Verifying your patient’s medical insurance should be one of the first steps performed once you obtain the patients demographics. You most certainly need to verify insurance benefits before arrive at your practice. Knowing if their plan is active, and if you are going to get paid for the care provided is critical. Basic information like co-pay, deductibles, and co-insurance are the essentials needed to see the patient. But what if you want to know about reimbursement for a photo, OCT or punctal plugs? Do you know if the procedures are covered by their insurance? Is there a routine vision benefit under their medical insurance plan? Do you know what you are required to collect financially from the patient at the checkout? OR, do you know if you are on the medical insurance plan as a provider or if an Optometrist can see the patient under their insurance plan?

Verification of your patients insurance is not just a way to determine if you are going to get paid, it is good customer service. It is a great way to educate your patients on what their insurance covers for medical eye care. Verification of benefits is critical in avoiding claim denials and non-payment of claims. Overall, it is a very good way to avoid many headaches!

What is the difference between Medical Insurance Eligibility vs. Insurance Verification?

Insurance Eligibility and Verification is the process of verifying a patient’s insurance plan benefits to determine their insurance coverage. Not validating coverage often results in billing errors creating payment delays across government and commercial insurance companies. With the introduction of the Health Care Exchanges, verification of coverage is paramount to knowing what you can do and if you will be paid.

There are two levels of validating patients’ medical insurance benefits. The first is called Insurance Eligibility. Eligibility is validating the basics of the patient’s medical insurance. The basic information is determining if the patient’s insurance is active, what is the co-pay, deductible, the out of pocket level, and possibly the co-insurance levels. Eligibility can be obtained online through an electronic portal.   Basic insurance eligibility is limited but does provide enough information for an office visit (exam) and knowing what to collect in most cases.

The second level is Insurance Verification and provides greater detail. The verification is where a telephone call is placed to the medical insurance company and you speak with a representative to obtain the patient’s medical insurance benefits. This call can last from 20 to 45 minutes per patient depending on the wait time for the representative to answer and the depth of information you request. When a call is made, you are validating the same information as the eligibility but you have the opportunity to ask any questions, digging deeper regarding the patient’s ophthalmic benefits.

Specifically, you are digging deeper into what procedures are covered, if you are in or out of network, and if a routine vision benefit exists under the medical plan. Most practices do not know the questions to ask regarding all of the ophthalmic procedures that the patient may have covered by their medical insurance plan. This information provides you a scope of coverage to educate your patient on what medical care an Optometric Physician can provide.

What are my choices for Insurance eligibility and verification of medical benefits?

Websites exist with each major insurance company that allows online eligibility. Also, some of the clearinghouses provide online access to check patient eligibility. These sites vary in degree of difficulty to access, limited ability to validate patient information and present HIPAA compliance problems with multiple user access with one set of credentials.

For more in depth information on the patients insurance, a phone call has to be made. This takes staff time to make the call and typically the questions asked only pertain to your immediate needs. The questioning doesn’t go deep into understanding all of the benefits you are able to provide for that patient medically. Also, staff typically does not adequately document the call results preventing this information being used if the claim filed is denied.

Consider using a professional service and software platform to get accurate and timely information. Also, the professional service can serve as an educational resource in understanding the verification results as well as your source for training. The outsourcing of insurance verification will ensure consistency of information, accuracy of information and documentation of the record. Documenting the insurance verification results will allow for a resource to be used in case of resolving a claim denial. In many cases, this report will provide the support required to justify claim reimbursement. Staff can dedicate the time taken for verification and focus on patient care tasks that generate goodwill and revenue for the practice.

For more information on Insurance Eligibility and Verification tools, contact OMS. You can contact Jerry Godwin at 210-249-0234 ext 4 or email at