According to Maria Feliciano, the Office Manager of Retinal Vitreal Consultants in Chicago, insurance issues have led to confusion and inefficiency, resulting in wasted time and uncertain reimbursement. “Many patients are presenting new plans to us – in some cases, plans with which we have no knowledge or experience. Each plan has to be fully investigated, which requires a significant time investment by our staff,” she explains. Furthermore, Feliciano says, the practice is losing patients due to changes in insurance coverage. “Some of our patients with Medicare, Medicaid and Illinois Medicaid have been switched to HMO insurances that we currently do not participate with. We are in the process of becoming a participating provider for these insurances, but it can take between to 3 to 6 months for approval,” she explains. Those patients who are turned away are sent back to their primary care physicians, so they can be referred to in-network providers. Thus far, this has affected about 25%-30% of the practice’s patients.

New Plans Slow Practices Down
Determining eligibility under new and emerging insurance plans can be burdensome for a practice, but it’s also confusing for patients. Feliciano says many patients believe that since they have insurance, they have coverage for everything. “A majority of our patients are elderly, and don’t understand what is covered under their new plan and what is not,” she notes. According to Nicole Ramirez, Assistant Office Manager of Retinal Vitreal Consultants, many patients are unprepared for the high out-of-pocket expenses that accompany some treatments. “We spend a good deal of time trying to explain insurance plans to patients. Many times, we don’t know exactly what will be covered under the newer insurance plans. Furthermore, many plans require a $6000 deductible; patients may not understand this and often get quite upset when they learn what this means to them.”

Staff members handle these issues by conducting online research and calling insurance companies to better understand each patient’s individual coverage. Members of the staff also call primary care physicians to obtain the proper paperwork and referrals, all of which is a time-consuming endeavor.

Bridging the Gap Between Patient and Provider
The goal of a retina practice is to provide care and treatment to the patient. To reach that goal, the staff often need to act as patient advocates. “To avoid losing patients, we have to do research for our patients, and become participating providers for their insurance companies,” Feliciano says. “Our practice is a well-oiled machine, comprised of a good group of people. As long as we maintain communication between our staff and patients, and remain the liaison between the patient and his or her insurance company, we can continue to be efficient and provide our patients with the best possible care.”