Find your way with 5 tips for managing your managed care plans—and getting paid

i’ve heard it called the “veil of confusion.” It’s that seemingly intentional, vaguely defined, changing, and/or frustratingly complex way that insurance companies set up their rules and regulations.

How do they determine whether you will get paid this time (or not) for the services and materials that you have already provided for your patient, anyway?

Shouldn’t this be pretty straightforward? You’d think. But, listen up…you chose to be a provider for that insurance company that is making you crazy, so you have to play by its rules. If you don’t want to play, then you might as well quit the game. That’s the hard truth.

The other truth is that to continue to thrive and enjoy your practice, you will probably need to keep accepting a good number of plans, perhaps both vision and medical types. The holy grail of being a 100% private-pay practice is just that, a holy grail…at least if you want to provide high-quality care, rather than deeply discounted and basic care.

Since you probably have to play, keep in mind these five tips to help get paid:

1. KNOW EACH PLAN.

Medicare, OHIP, or whatever the government insurance carrier is within your country/province may set the ground rules, but every individual plan gets to decide if it wants to add its own “special” requirements. Study and understand each carrier’s guidelines in order to get paid optimally. Don’t assume you know it. Read the fine print.

This leads to the next very critical tip…

2. HIRE + TRAIN A CAPABLE INSURANCE COORDINATOR.

Yes, as the owner/practice administrator/executive team, you are in charge of evaluating each plan’s reimbursement schedule, along with its rules and regulations. You are responsible for deciding whether to participate or not initially. However, you need someone who can take it from there and make sure you stay informed about that plan once you’ve picked it. Enter: your insurance coordinator.

3. REQUIRE MONTHLY AGING REPORTS + ANALYSIS.

You should look at your aging report regularly, and your insurance coordinator should give you a rundown of any issues with specific carriers, unusual denied claims, and new information they’ve received from the companies regarding guidelines. You should have a benchmark for total account receivables (we like the average of the last three months of collected receipts). There should be a progress report and a plan of action on attaining or maintaining that goal.

Don’t just talk about it! Don’t just look at a printed report. Have your insurance coordinator show you in your software, clearinghouse, and insurance carrier interface how they came up with these numbers and how it works. You should also have a monthly write-off report showing the different categories of write-offs: Contracted Insurance Write-offs, Courtesy, Timely Filing, Sent to Collections, Corrections, Employee Benefit, etc.

4. HAVE A BACKUP.

It is a bad idea to be dependent on any one person capable of handling any aspect of your practice. When it comes to cash flow, this is especially important. It is very common to end up with only one person who knows how to submit claims or reconcile payments. There should be another person who can proficiently keep things going if the primary insurance coordinator is out of the office for any reason.

You must cross-train and keep excellent procedure manuals. Many practices now contract with an outsourced billing service for just this reason. Sometimes it can be challenging to keep even one employee in-house who is proficient in insurance.

5. RANK AND EVALUATE PLANS ANNUALLY.

Just because a plan was good last year doesn’t mean it is still good this year. Study each carrier’s guidelines every year, and make sure you are OK with its requirements and reimbursements. For vision plans, create lens lists and options that not only serve your patients well, but that result in a profit margin for you.

This is not easy (remember that “veil of confusion”?), but it must be done if you wish to have a profitable business, not just “busyness.”

We can wail and rail against insurance companies as much as we want, but it doesn’t change the fact that we need to work with them. Roll up your sleeves and dig in.

There is still plenty of profit to be made in optometry. Start with a strong patient care ethic and build sound cash flow practices atop that ethical base.

—Bess Ogden

BESS OGDEN, a senior consultant and implementation specialist with the Williams Group since 2006, has helped hundreds of optometric practices. She earned a B.A. from Dartmouth and has extensive experience in finance and management. Notably, she excels in helping optometrists reach their full potential in areas such as leadership development, staff engagement, financial analysis and growth projections, accounting systems management, and operational foundations and sustainability. thewilliamsway.com