At Professional VisionCare, we want to be accessible to as many patients as possible, as we want everyone to have the opportunity to experience the awesomeness of our quality vision care! As a result, we have worked hard to become in network providers for a wide variety of medical insurance plans and vision benefit plans, which we will talk about in this section. We will also discuss how to handle patients who have no insurance or are “out of network,” as they are considered “cash” patients. Lastly, we will discuss how to investigate which vision benefits are patients have, and how to pull authorizations for their upcoming appointments. This is all super important stuff, so buckle in and let’s learn!

One of the KEY responsibilities of the Patient Relations team is accurately collecting patient insurance and vision plan benefit information and documenting on patient charts, and using that vision plan benefit information to pull authorizations/check benefits for upcoming appointments. These skills are VITAL to master, as failure to do so causes complications for your team members, other departments, and ultimately, our patients. It is tough to master, however, due to the vast number of changes that occur in protocol and the number of details to remember. Please read through this training ENTIRELY, and ask questions if you have any!

Collecting benefit information from the patient

Gathering the correct information from patients upfront is incredibly important, and will set you or your team members up for success when it comes time to verify their benefits for their appointment. Most errors START here or could be AVOIDED ENTIRELY if we are more diligent about collecting the most up to date information right when patients schedule their appointment.

To start, when a patient calls, emails, or texts us asking to schedule an appointment, once we verify their demographic information (or create a new one for new patients), we should immediately discuss their benefits.

• The CORRECT WAY to open the conversation about what benefits the patient has is to ASK AN OPEN ENDED QUESTION, such as “This year, what vision plan and medical insurance do you have?” or “What vision plan would you like us to bill for this visit?” 

• Forming the question in this way allows the patient to consider what benefits they may have, and requires them to think about it, providing you a more accurate response.

• Here is the INCORRECT way to ask this question: “Do you still have VSP this year?” or “Is your insurance the same as last year?” With these questions, the patient doesn’t have to think about their benefits and will likely assume that we have the correct info on file, when in fact we might not!

• When the patient responds with WHAT vision plan they have, double check with them that the account responsible is who you have listed (or for new patients, add a new tab in the insurance section).

• Double check that you have ALL the information required, and add/edit anything that is missing:

  • Account Responsible’s Name with the correct spelling

  • Acct Responsible’s DOB

  • Account Responsible’s Gender

  • Relationship to pt

  • ID number (the full social security number is necessary more often than not, so if you run into any challenges getting the full social, just let them know that in order to use their benefits, we will need the full social security number. If they absolutely refuse, let them know that you can try to pull with the last 4 digits, but if that doesn’t work, they need to be on the lookout for a follow up phone call/text).

  • Change the insurance to a “1” as this will be the primary biller for their exam.

  • Make sure the “Plan” field on their demographic has the correct vision plan listed (or medical insurance if they don’t have a vision plan).

• In this day and age, even when we ask the patient what plans they have, they still do not know. If you run into a patient who does not know what benefits they have, at THIS point you can offer some help, such as “I see that last year you had VSP for your vision benefit. Have you or your employer changed this benefit within the last year?”

• If they are unsure still, offer to quickly check their vision benefits on their website, as we want to make sure they are able to utilize their benefits (and because we want to make sure we have correct information!).

• For medical insurance, you do NOT need to add a tab during the phone call/email/text. But you DO need to let the patient know that we are happy to bill their medical insurance, and just as a heads up, if they have not yet reached their deductible for the year, some of the exam charges may be applied to that deductible and a bill will be sent to them. Make NOTES in the appt that you had this convo (i.e. “wants to bill med ins, discussed financial responsibility/your initials”). 

• If a patient has NO insurance/vision plans or has a plan that we are not providers for, make sure they understand that they will be responsible for all fees at time of service. Make notes regarding this, and make sure that you have expired out any previous insurances, and change the plan to “Self Pay.”

• What if a patient schedules through the online appointment scheduler? Most likely, you didn’t receive all of the information you needed to confirm/update/add new vision plan benefits. Here’s what you need to do after you confirm that pt’s requested appointment:

  • Through text or by phone call, contact the patient and let them know that you just saw they chose an appointment with Dr ____ for (date). Thank them, or let them know that you are excited that they are coming in for an appointment!

  • Then, let them know that you are already preparing their electronic chart and wanted to make sure everything is in order for when they arrive to their appointment, so you just have a few pieces of information regarding their vision plan benefits that you need to verify/obtain. (or some variation of this message J)

  • Update the information in the pt’s screen, and still make notes in the appt notes that this was an online appt, and that you called/texted and got updated ins info.

• When a patient calls into to RESCHEDULE their exam appointment, you STILL want to follow all of the above steps! Ask, verify, update, and make notes. This is ESPECIALLY necessary since many exam reschedules are done for annual exams, which as you know, are scheduled one year in advance and may very likely have changed benefits!

• All of the above steps will ensure that YOU have done everything you can to provide you/your team the most accurate information possible, which will in turn help you/your team successfully check and pull authorizations when the time comes. J

“pulling” vision benefits in advance

Every day, you/your team members are tasked with the challenge of preparing vision plan benefits for the patient’s exam the following week. If they have VSP, you need to pull an authorization. If they have Eyemed, you need to verify and scan their benefits in their demographic. Seems so cut and dry, and yet, as we all know, you have to practically become a private detective to investigate and solve the “case of the missing vision plan” over and over and over. So we have put together a training that will outline the HOW to pull vision benefits and check patient eligibility that is a sure fire way to make sure no benefits are missed! We created an “Pulling/Verifying Vision Plans Benefits Flow Chart” that will literally guide you through investigating benefits for EVERY patient, and here is a quick peek at it! Read through the chart fully, and please note: if the patient has Spectera, you will follow the same flow as the Eyemed box on the chart, but go to the Spectera website instead. Once you have looked through the chart, keep reading for the written out protocol for each of the following tasks in PR: Checking Eligibility One Week in Advance, Checking Eligibility the Day Before, and Checking Eligibility Same Day. It’s a lot to learn, but you will be a pro before you know it!

Checking eligibility one week in advance

• Whichever team member is responsible for checking insurance/vision plan eligibility one week in advance will pull up the schedule they are checking as per usual, and for each exam, they will start at the beginning of the new “Pulling/Verifying Vision Plan Benefits Flow Chart.”

• They will follow that flow chart, fulfilling each box’s requirements until they get to the “Finish Line” at the end. They will NOT proceed to the next exam on the schedule until they have reached the Finish Line for the appointment they are working on.

• For EVERY appointment, you will not reach the finish line until an alert message has been made. So from here on out, EVERY exam will have an alert message with details regarding their vision plan/ins eligibility, and with an expiration of one month past the date the message was made.

• Following this flow chart will be applicable to ALL plans EXCEPT for Medicaid and Medigold.

  • For Medigold, follow the VSP section of the flow chart.

  • For Medicaid, you must check their Medicaid eligibility on the www.ohmits.com website as per usual, and make an alert message stating the eligibility info you found. If you need the SOP on how to do this, please let RAM know. This was not a common error, so not a lot of time will be spent on this.

• Once you have finished following the flow chart for every exam on the schedule, add “Vision/Ins Checked One Week Out” with your initials in the schedule’s daily notes, as per usual.

Checking eligibility day before:

• Whichever team member is responsible for checking insurance/vision plan eligibility the DAY BEFORE the appointment will have a much easier time knowing if the patient’s benefits are ready to go or not, because they will have an alert message created that identifies what benefits they have or the status of their benefits.

• So, this team member will pull up the schedule, and go through each exam.

  • If they reach an exam that DOES NOT HAVE AN ALERT MESSAGE MADE for the upcoming appointment, they must follow the flow chart from start to finish line for that appointment, and create an alert message.

  • If they reach an exam that has an alert message that is WAITING TO HEAR BACK FROM PT REGARDING BENEFIT INFORMATION, they will attempt to contact the patient a second time, and document in that same alert message that they reached out for info a second time, or if they reach the patient, they will update the patient’s demographic and insurance tabs with the correct information, and follow the flow chart.

• When they finish checking all exams on the schedule, they will add “Vision/Ins Checked Day Before” with their initials in the schedule’s daily notes, as per usual.

Checking eligibility day of-this is for the front desk crew:

• Whichever team member is responsible for checking insurance/vision plan eligibility the DAY OF the appointment at the front desk will have an even easier time knowing if the patient’s benefits are ready to go or not, because unless a random appt was added last minute, EVERY EXAM SHOULD HAVE AN ALERT MESSAGE.

• So, this team member will pull up the schedule, and go through each exam, same as before, except:

  • If they reach an exam that DOES NOT HAVE AN ALERT MESSAGE MADE for the upcoming appointment, they must follow the flow chart from start to finish line for that appointment, and create an alert message.

  • If they reach an exam that has an alert message that is WAITING TO HEAR BACK FROM PT REGARDING BENEFIT INFORMATION, they will make a special note on their printed schedule at the front desk to VERIFY this info as soon as the patient checks in, so that all the details can be cleared well before they check out with an optician.

Vision Plan Benefits and Insurance are A BEAST, and they don’t make it easy, but it’s an important part of our jobs, so I thank you for taking the time to read through this training, and I’m excited to see you THRIVE in this role! There is just one section left in this module, and it’s how to check Medicaid eligibility. You are on the home stretch!  

Checking Medicaid Eligibility SOP

When scheduling appointments for Medicaid patients, it is EXTREMELY important that we do not schedule patients who are under Molina, CareSource, MyCareOhio or another Medicaid plan not in our network. We run into a number of very serious issues with patients who have these plans and come in to our office without our knowing this. We may have to charge the patient out of pocket, or even turn them away – definitely NOT a conversation we want to have with an angry and confused patient!

Thankfully, the wonderful Finance team and Anita have found a way for us to check a patient’s Medicaid eligibility PRIOR to them coming in for an appointment!

Moving forward, checking eligibility must be done for ANY AND ALL Medicaid patients that we schedule PRIOR to them coming in for an exam. If you are scheduling a patient in person or over the phone, we should be checking this while we’re with the patient, to avoid the icky scenario of having to call them back to tell them we can’t see them.

SO, want to know the magical secret? WELL…..

• Go to www.ohmits.com

• Log in to using the office you are working from’s username and password

  • WV USERNAME – provis1

  • Password – 43081pvc

  • JT USERNAME – provis2

  • 43031@jt

  • TSC USERNAME – provis3

  • 43082pvs

• Check that “YES, I have read the agreement” and LOG IN

• Enter the security code from the picture

• Click “SECURE PROVIDER PORTAL”

• At the top of the screen you’ll see a tool bar. Drag your mouse over “ELIGIBILITY” and click “ELIGIBILITY SEARCH”

• This takes you ELIGIBILTY VERIFICATION REQUEST

• Enter the Medicaid Billing number or SSN

• Enter DOB

• Click SEARCH

• Scroll down the page until you see the MANAGED CARE section

• Make sure the patient does not have –

  • Caresource

  • Molina

  • MyCare (may also say Buckeye Community Health plan)

  • Any other plan listed here

• If they’re out of network, they need to find an in-network physician

• If there is NOTHING listed (will say ***No rows found ***), then the patient has Ohio Medicaid

You can also check the patient’s Medicare!

1)      Go to the MEDICARE Section

2)      Using the above information, if the patient has Medicare, their information will be here

3)      NOTE: If the patient has both Medicare AND Medicaid, Medicare is the primary payer, Medicaid is the secondary

TO LOG OUT –

• Account

• Log Off

• Close Window