Many aspects of practicing medicine in today’s world have little to do with the actual practice of medicine, and most physicians would not be sorry to see them disappear into the sunset. One of them is dealing with insurance companies. Although insurance is—in theory—a good thing for patients, outside of Medicare it’s largely a for-profit industry. That means that while insurance can keep patients from being financially overwhelmed by an unexpected medical crisis, insurance companies have plenty of motivation to deny patient claims as often as possible and to negotiate contracts with doctors that squeeze practice budgets.

This certainly doesn’t mean that dealing with insurers is all doom and gloom, but it does mean that any interaction is a negotiation. For that reason, you need to approach dealing with insurers strategically, both for your benefit and your patients’. Here, surgeons share what they’ve learned about interacting with insurers to get the best possible results for your practice and your patients.

The Trouble with Insurance

While most surgeons have encountered numerous situations in which insurers have balked at providing coverage, there are a few that come up frequently.

“The insurance companies have lots of guidelines, especially in terms of step therapy,” says Mark Packer, MD, FACS, president of Mark Packer MD Consulting in Boulder, Colo. “We see that a lot with pharmaceuticals, where they place limits on the more expensive therapies; we can’t prescribe Restasis or Xiidra until we’ve exhausted artificial tears and any other treatment options. We also see extensive guidelines for procedures that are performed frequently, like cataract surgery, and for procedures that may or may not really be medically indicated. The big one in the latter category is blepharoplasty, which can be performed to address a functional problem but may also be performed for cosmetic reasons. The insurers want to see a visual field test confirming a functional problem before they’ll agree to pay for it.

“It’s pretty clear that the prior authorization process that commercial insurers have is a cost-saving measure,” he continues. “The companies want to have their person look at your chart and decide whether or not procedures X, Y and Z are actually indicated and within their guidelines. So we put together a dossier for a given patient which will hopefully convince the medical reviewer that our patient needs cataract surgery, a blepharoplasty, a prescription for Restasis or whatever it is.”

“Today, Medicare is easier to deal with because we have a pretty good idea of what it will pay for,” says Robert J. Noecker, MD, MBA, an assistant clinical professor at Yale University School of Medicine, clinical professor at Quinnipiac University, and in private practice at Ophthalmic Consultants of Connecticut in Fairfield. “It used to be that people would worry about leaving their commercial insurance, but today Medicare is the most transparent insurer. No one’s getting rich off of it and Medicare patients understand exactly what they’ll be paying for.”

Denials for Drugs

One big insurance company hurdle that frustrates ophthalmologists is approval of the use of brand-name drugs. “We regularly get denials for medications like Xiidra and Restasis and brand name anti-inflammatories,” says John A. Hovanesian, MD, a specialist in refractive surgery, cataracts, cornea and external disease at Harvard Eye Associates in Laguna Hills, Calif., and a clinical assistant professor at UCLA Jules Stein Eye Institute in Los Angeles. “In those situations we decide on a case-by-case basis whether it’s worth pushing back. Unfortunately, the number of denials is increasing.”

Dr. Noecker notes that this is especially problematic when patients need to use a drug on a chronic basis, such as topical drops for glaucoma. “There’s a really big push toward fewer and fewer medications being covered,” he says. “That’s especially true for branded medications, but even the spectrum of things that used to have relatively low copays has shifted. As recently as last year, some branded medications cost the patient $30 or $40; today they cost $60 or $70. Some of them have been dropped from formularies altogether, while others have gone from $50 to $200. That’s really disruptive for the patient.

“It’s also challenging for the doctor,” he continues. “It’s a lot of work to figure out what works best for a given patient. Over a few visits you determine that one drug seems to work best for the patient in terms of side effects and efficacy. Then you have to throw all of that out the window because it’s a new year and the drug that was working for the past five years now costs four times as much. We have to start from scratch to find an alternative medication that will be just as good as what the patient was using before. That means more work for both the doctor and the patient, and if the patient has glaucoma it increases the risk of progression. That’s a serious problem, because if the patient gets worse while you’re trying to find an alternative drug, you can’t undo the damage; the vision loss is permanent.”

Dr. Noecker notes that the setup is particularly unfair if a drug isn’t covered by insurance at all. “When patients pay for a drug, they pay the full cash price,” he points out. “The insurance companies get significant rebates, as much as 50 percent off, but patients don’t get that. Why should the patient have to pay more than the insurance companies are paying? The system is crazy.”

Three More Obstacles

Dr. Noecker notes three additional issues that he’s found troubling when dealing with commercial insurers: First, some insurance companies are refusing to cover medications for cataract surgery on the second eye until some arbitrary amount of time has passed since the first surgery. “With many patients, we do one eye and plan to do the other eye a few weeks later,” he says. “More and more insurance companies are saying, ‘It’s too soon—we won’t pay for another bottle of antibiotic.’ In reality, it’s a new surgery for a new eye and these medications are the standard of care, so this is a big problem, even if we try to help the patient out with samples.

“We never used to see this,” he continues. “Patients used to get whatever they needed to have a successful outcome. It’s troubling when the patient has a very good surgery and we expect him to do well, and then he can’t get the eye drops. That puts the patient at risk of an infection or prolonged inflammation, which can mean poorer vision and a slower rehab. It’s a source of frustration for us and a source of anxiety for the patient.”

Dr. Noecker says insurers are also being difficult about the newer glaucoma surgeries. “We’re seeing increasing pushback when we try to use MIGS devices like the iStent, CyPass or Xen implants,” he notes. “These things are available and FDA-approved and patients read about them, but we can’t use them because the insurance won’t cover them. Patients have to pay out of pocket if they want these newer, more advanced technologies. I’ve even seen insurers categorize canaloplasty as an ‘experimental procedure,’ although it’s been in use for a decade.”

A third issue Dr. Noecker notes is carrier unwillingness to pay for combined surgeries. “A patient may have both glaucoma and a cataract, but some insurers won’t allow the two surgeries to be done at the same time,” he says. “We have to choose which to do first, which is absurd. Which one should we say is more important: the patient’s risk of going blind from glaucoma, or difficulty functioning because of the cataract? It’s a bad thing that clinical decisions are being made based on insurance company dictates that are difficult to even understand. In a situation like this, doing the two surgeries separately increases patient risk. It’s more expensive because it’s two rounds of anesthesia and two trips to the surgery center, not to mention two sets of postoperative drops. And it doesn’t even make sense for the insurance company: The company pays us more if the surgeries are separated than if we do them at the same time. So what’s the rationale?

“This is illogical, and it creates a suboptimal decision-making process,” he says. “We’re no longer telling the patient what we think is best; we have to mitigate it, finesse it. The patient says, ‘Is this the best thing for me, in your judgment?’ And we have to say, ‘No, this is what your insurance company will pay for.’ Then we have to explain why we’re doing something that’s not optimal for the patient. It creates a conflict. We can’t be the patient’s advocate.”

Dr. Noecker notes that, as frustrating as it can be to deal with insurance companies, patients get the worst of it. “Premiums are going up every year and deductibles are rising as well,” he says. “Some patients have cataract surgery on one eye in December. When they go to get the second eye done in January, not only is the new year’s deductible not met, but the costs to the patient may be higher for 2017. We can usually tell what’s covered by insurance and what’s not, but the details can be hard for us to predict with so many carriers and so many plans at each carrier. Patients can get hit with a pretty big bill for the uncovered part of the surgery.”

Justifying Borderline Cataract

Another issue when dealing with insurance companies—including Medicare—is convincing them to cover a procedure when the patient’s condition is considered borderline. Dr. Packer is focused primarily on performing cataract surgery; he encounters this problem when a cataract is troublesome for the patient but doesn’t meet basic criteria such as poor visual acuity. “Medicare carriers have a certain threshold at which they say, ‘OK, cataract surgery is indicated,’ ” he notes. “For most of them it’s a best corrected visual acuity of 20/50 or worse. There’s usually also a stipulation that if the patient meets that threshold under conditions involving glare, that patient is covered—as long as glare is an issue for the patient.

“However, there are some subtleties about this that many surgeons don’t fully understand,” he continues. “Suppose a patient comes in and says, ‘I’m having a lot of difficulty reading fine print these days, especially in dim light.’ You find that the patient’s best corrected acuity is 20/20; then you do a glare test and it’s 20/60. You might conclude that because of the glare test, this patient can have cataract surgery. However, there’s an important issue here: The patient didn’t have a complaint relating to glare. Yes, the test showed diminished acuity in the face of glare, but that didn’t correlate with the patient’s chief complaint: trouble reading fine print.

“In order to invoke glare test acuity as the rationale for cataract surgery, there must be a complaint from the patient about glare,” Dr. Packer explains. “The patient must be saying something like, ‘I’m having a really hard time driving at night. Oncoming headlights really disturb my vision.’ Or, ‘On a bright sunny day, I have trouble seeing the edge of a curb when I’m walking down a city street.’ You can only invoke the glare clause when the patient has some real-life complaint relating to glare. That’s a point doctors often miss.

“The reason I bring this up is that, fundamentally, cataract surgery is done to improve quality of life and prevent things like motor vehicle accidents,” he says. “It’s not really done to improve visual acuity by some specific amount. Visual acuity is an artificial clinical test that’s supposed to reflect something about how people see in the real world. That’s why the most important thing is what the person is complaining about, and whether that complaint is attributable to the cataract. Also, beware if a patient says he has no complaint, regardless of his less-than-ideal best corrected visual acuity score. A Medicare auditor will want to know why you did the surgery if the patient said he was fine and had no complaint.”

Dr. Packer adds that a technician is usually the one who writes down the patient’s complaints, along with test scores. “Noting the nature of the patient’s complaint is therefore a technician-training issue,” he says. “Of course, it’s ultimately the surgeon’s responsibility, because it’s the surgeon who will have to pay Medicare back if Medicare concludes the procedure wasn’t justified.”

Beyond Visual Acuity

Dr. Packer says that one tool that’s effective at supporting the need for cataract surgery is a validated questionnaire. “The one that I’ve used most frequently, which we can perform in the office, is the VF-14,” he says. “It’s available online and not hard to find. It contains 18 questions with multiple answer options for each question, most ranging from ‘never’ to ‘all the time.’ The final score is a percentage, and it drops down from 100 percent as visual dysfunction increases. It can be very helpful in determining whether someone might benefit from cataract surgery. If the patient scores 99 percent, that’s going to be a stretch because there’s not much room for improvement. Seventy-five percent is a pretty good threshold, and there’s good evidence that if a patient scores 75 percent on the VF-14 and then has cataract surgery, he’ll have a pretty high level of satisfaction afterwards.1,2 The surgery will improve his visual function and he’ll be glad he had it.

“The patient can do this questionnaire while dilating, sitting in the waiting room,” he continues. “Then, when the doctor comes back in, the results are available. Or, the patient can fill it out as part of a patient information packet, done before the visit and submitted through your patient portal online.

“The VF-14 is particularly good in a Medicare-audit situation,” he notes. “It provides hard evidence that cataract surgery was appropriate in cases where the BCVA was better than the threshold of 20/50. It’s also helpful when making the case for a commercial insurer’s medical reviewer. It can be very persuasive in either situation.”

Dr. Packer says another test that’s helpful for supporting the need for cataract surgery is contrast sensitivity. “Contrast sensitivity testing picks up reduced visual function far in advance of declines in best corrected visual acuity,” he notes. “This can be done using a wall chart, but the best option is an instrument the patient looks into, like the ones at the motor vehicle bureau. In those, the illumination is controlled and you can dial in the patient’s spectacle correction.

“These tests compare the patient’s contrast sensitivity to a normative range at four or five different spatial frequencies,” he continues. “Normally, if the patient scores 0.3 log units below the mean at any spatial frequency—it doesn’t have to be at all spatial frequencies—that’s a compelling argument that cataract surgery will improve vision.”

Dr. Packer notes that you may have to explain to an insurance company’s medical reviewer what the contrast sensitivity score means, either in a cover letter or over the phone. “Medical reviewers are not always familiar with the significance of contrast sensitivity,” he says. “It’s great to have a couple of peer-reviewed publications in your back pocket that you can cite to back up what you’re saying.

“As long as I have convincing scores on the VF-14 and contrast sensitivity tests, I’ve always been able to get the cataract surgery covered after a denial,” he says. “It’s an extra effort, but it can make patients very happy. Obviously you want to do these tests as soon as you realize a patient is a borderline candidate; you don’t want to have to bring them back in later to contest a denial. Make sure your technicians understand this.”

Dr. Packer notes that you shouldn’t send the extra supporting data in when you first ask for authorization. “When you first apply for approval, you’re just going through a computer program,” he says. “The computer won’t even look at all of this, and it may create issues. So you want to wait for the appeal and then send this in, when you know that an actual person is going to look at it. And of course, if the patient meets the best corrected visual acuity criteria of 20/50 or worse, I can guarantee they’ll do poorly on the VF-14 and have reduced contrast sensitivity, so there’s no reason to put them through those additional tests.”

Negotiating for Your Patients

Doctors suggests these strategies to increase the likelihood that you’ll get your patients the treatment they need when an insurer denies the claim:

Make contesting insurance company denials an acknowledged part of your practice. “I think it’s important to say, ‘Doing this is important for our practice and patients,’ rather than just trying to deal with it once in a while,” says Dr. Noecker. “It helps to have a protocol in place for dealing with insurance companies. Of course, there’s no way to understand all the intricacies of every payer plan, but just understanding what will probably go through does make a difference. And it’s important to know how to respond when claims are denied.”

Dr. Packer says the number of denials a practice will receive depends partly on the demographics of the patient base. “Working people in the Midwest may be inclined to postpone coming in to see you until the cataract is clearly eligible for surgery,” he says. “But if you’re practicing in a big city on either coast, you’ll probably see a lot of borderline eyes.

“If your practice receives a lot of denials, you may want to have a full-time person whose job is to talk to insurance companies all day long,” he adds. “However, be forewarned that that employee will spend a lot of time on hold. I suspect that keeping callers waiting is an insurance company strategy to reduce costs. Such an employee will probably be able to do other kinds of work for you as well while they’re listening to the on-hold music.”

If your medical decision is being influenced by insurance coverage, make sure patients know that. “Doctors are being made to look like the bad guys,” says Dr. Noecker. “When we’re forced to do two surgeries instead of one combined surgery, for example, I think we have to make it clear that it’s the insurance company that’s insisting on something other than our best judgment about what needs to be done.”

Don’t hesitate to challenge a denial. “I believe in fighting the fight, because if you give in on one thing it opens up the floodgates,” says Dr. Noecker. “Of course, you have to decide how much time you want you and your staff to spend on this kind of thing. It’s not financially beneficial to the practice; it’s just the right thing to do. We have to let the insurance company know that this is what we’ve determined is best for the patient.

“In our practice we push back on everything,” he continues. “Our staff automatically files requests for prior authorization forms. About two-thirds of the time, that’s all we have to do—just sign the form and explain that this is standard of care, or that it’s the best thing for this patient. Automatically filing for prior authorization is an extra step, but I look at it as a relatively trivial step.

“Sometimes you don’t get an immediate approval and you have to go a little deeper,” he says. “You may have to list the options the patient has tried and failed, or explain why the option the insurance company wants is inappropriate—what the risk to the patient is. Glaucoma is a blinding disease, and I have no problem saying that this patient needs this therapy and could have irreversible blindness if we make any missteps. I’m also happy to point out that the next step will be surgery if the patient can’t get this medication. Insurers will find that surgery is a much more expensive undertaking than an eye drop.”

Dr. Noecker acknowledges that the extra effort won’t always pay off. “I’m pretty aggressive, but sometimes I do hit a wall,” he says. “I typed 10 pieces of paperwork to get one patient covered for topical cyclosporine (Restasis), but her insurance plan would not allow it no matter what. I detailed how her dry eye was disabling her at home and at work, but the carrier wouldn’t give in. Luckily, most of the time you can get what the patient needs if you go through the process.”

Persist until you talk to a medical director. “Often, I’ve had success after escalating the matter to a medical director at the insurance company,” says Dr. Hovanesian. “At every insurance company that I’ve dealt with they have a process for escalating appeals that usually concludes with talking to a doctor. It’s typically a phone call, so it doesn’t require writing a letter. During that phone call you get to state your case.

“Usually, you don’t end up talking to an ophthalmologist,” he continues. “When you do, you’re lucky because you can speak in shorthand and they understand your situation. Often these individuals are doctors who practice part time or don’t practice at all, but they understand the physician’s perspective and they’ll usually grant a reasonable request. Actually, when the doctor is not an ophthalmologist, he may be even more likely to give in on a request because he won’t have the knowledge of your specialty to make a good argument for denying the claim.”

Dr. Hovanesian says that he argues for a claim to the point of talking to a medical director several times per year. “Sometimes just requesting a review with a medical director is enough to get a denial overturned,” he says. “The representative will just say, ‘OK. He’s busy, we’ll approve it.’

“I believe that when a patient needs a treatment and an insurance company is denying it, it’s simply an insurance company strategy,” he adds. “They’re hoping to create enough barriers that you’ll give up so they can avoid the expense of covering the treatment. By persisting, you show that the request is legitimate, and that you want the patient to receive proper, modern treatment. You also pave the way for future patients because you help to set a precedent with that insurer for what constitutes appropriate patient care.”

Like Dr. Hovanesian, Dr. Noecker has noted that the medical director you end up speaking to is rarely an ophthalmologist, but Dr. Noecker believes that can be a bad thing. “Sometimes if the doctor doesn’t have the ophthalmology background he’ll just read from the carrier’s manual, citing that what you’re asking for isn’t covered. Yes, sometimes the person is very reasonable; if I can show that I’ve documented everything, he’ll say OK. But sometimes he won’t budge. It’s one more source of variability.”

With Medicare, be proactive to protect yourself. Dr. Packer notes that one of the big differences between commercial insurers and Medicare is that Medicare has no prior authorization process. “You just do the procedure and submit your charge to Medicare, and they generally pay it,” he says. “However, doctors face the underlying threat that
When negotiating a contract with an insurance company, having data that shows you provide excellent care can get you better terms. (Most practices don’t provide this.)
Medicare may someday come to audit you. If they review 10 of your blepharoplasties and determine that nine of them were not medically indicated, they’re going to say that 90 percent of your blepharoplasties should not have been covered. If you’ve performed 1,000 blepharoplasties in the past 10 years, they’ll demand to be repaid for 900 blepharoplasties. Medicare counts on the threat of an audit to keep people following their guidelines. It’s all stick and no carrot.”

How can a practice minimize the risk of a bad outcome should an audit occur? “You can conduct you own practice stress test,” says Dr. Packer. “You can conduct an internal audit of your records, or better yet, hire somebody to come in. There are companies out there that will do a mock audit for you. They’ll point out weaknesses, so if you’re ever audited you won’t end up paying needlessly for mistakes.”

When a drug or device is part of a claim, the manufacturer may be your best ally. “The manufacturer has a vested interest in the patient receiving its device or drug,” notes Dr. Hovanesian. “For that reason, many companies have resources you can turn to, whether it’s a drug company with patient-access programs and coupons, or a company like Omeros [maker of Omidria] with a drug that requires prior authorization to get it reimbursed. Omeros has created a reimbursement program that maximizes the likelihood of insurance company approval and minimizes the work required from physicians and staff. They assist in the process of verifying that a particular insurance company will cover it. And, if the insurance company doesn’t end up covering it, they’ll often provide a no-cost sample, so I can use Omidria and feel pretty confident that it will either be covered or the manufacturer will provide a sample.” [To learn more about the Omeros program, visit]

Use preauthorization forms to help your patients. “Insurance companies are middlemen between patients and doctors,” notes Dr. Noecker. “They want to maximize their profits, so they’re going to encourage people to use whichever drug they’ve negotiated the best price on, for purely economic reasons. If your clinical analysis lines up with their economic motives, great. But if it doesn’t, then a preauthorization form allows us to override the insurance company. Part of this is educating patients so they know about this process, so they don’t end up not getting the drug at all or paying an excessive amount of money for it.”

Help your patients reduce costs with vouchers. Dr. Noecker points out that many branded drug manufacturers provide practices with vouchers that can reduce the cost of medications for patients. “Vouchers put a cap on the cost of the medications, which can reduce the cost from $200 to $30 in some cases,” he says. “As a result, it’s sometimes cheaper to use the branded medications than the generics. That’s especially true given the rising cost of some generics.
“The main issue with vouchers is remembering to use them,” he adds. “In our office it’s part of our surgical process; I have my surgical coordinator hand them out when our patients are getting their prescriptions. Vouchers help to keep costs predictable, but you have to take the time to explain to patients how to activate the card, and get the patient to take it to the pharmacy and present it when getting the prescription filled.”

Consider using third-party insurers to obtain some infrequently prescribed medications. “Some of the smaller manufacturers, like Akorn, have contracted with a third-party mail-order pharmacy,” says Dr. Noecker. “Using this route takes a little bit of staff work, but the price will be half or a third of what patients might pay at their pharmacy. So if someone needs preservative-free timolol, for example, this can keep the patient from being hit with a gigantic bill.”

Be aware that patients may be convinced that Medicare supplement insurance pays for premium services. “I had a relative who thought that her Medicare supplemental insurance would pay for having femtosecond-laser-assisted cataract surgery,” notes Dr. Packer. “Of course, it doesn’t, and she’d been told that. It’s just that with many patients the message doesn’t quite get through.

Patients often believe they’ll be covered, even if they’ve been told otherwise. Some believe it’s worth a try because maybe the supplemental insurance will cover it.

“This is a good technician training item, because the patient will often mention this idea to the technician in passing,” he continues. “That’s the moment to nip it in the bud and make it clear that no insurance company covers FLACS or a premium implant. By the time patients mention this to someone in your office, they’re usually easier to convince because they’re specifically focused on this issue.”

Get involved in the political process. Dr. Noecker points out that ophthalmologists have been successful at changing some insurance company policies that put patients at risk. “There was a time when it was not uncommon for insurers to tell patients, ‘We won’t refill your glaucoma medication yet because we covered a month’s supply and you’re only three weeks in.’ As every ophthalmologist knows, elderly patients often have trouble using drops correctly and end up finishing the bottle earlier than intended. If glaucoma patients are only receiving their drugs three out of four weeks, that can have profound consequences in terms of vision loss; it’s a huge public health issue. But thanks to many physicians talking to their state congressmen, it’s now the law in many states that insurers have to honor the refill, even if it comes in early.

“The point is that our political efforts can make a difference,” he says. “Once you explain the situation to the politicians, they get it, but you have to call it to their attention. So I think it’s really important to take action and remain engaged.”

• Remind the patient that if all else fails, she can change insurance companies. “Sometimes you just can’t get what you need from your carrier,” says Dr. Noecker. “However, if worst comes to worst you can always choose a new one the next time you’re up for insurance.”

Should You Sign that Contract?

The other side of the insurance company coin is the contracts you sign with them that determine, among other things, your level of reimbursement. The following three strategies can make a big difference in how fair a deal you end up with:

Negotiate to get the best possible terms in your contracts. “I’d say 75 percent of practices accept the contract they receive from insurance companies every year,” says Dr. Hovanesian. “The doctors lower their heads in disappointment at how reimbursement is going down, but they sign and return the thing in disgust, and that’s the end of it.

“Actually, there’s absolutely no reason to accept the terms that come to you in a contract, as presented,” he continues. “You should always negotiate to get the best deal you can. But when negotiating a payer contract—or anything else, for that matter—you have to understand the concept of leverage. What do you have that the other party wants? If you walk away from the table, what do they lose? You want to present yourself in the most favorable light so they’ll want to have you on their panel.”

When negotiating, have data on your side. Dr. Hovanesian notes that it makes a big difference to have concrete data showing that your practice has top-notch doctors providing first-rate care. His practice uses a unique software system called MDbackline (which he helped to develop) that accumulates data about the practice. “The software automatically contacts patients after certain procedures, office visits and surgeries, to determine how they’re doing,” he says. “It gives them real-time guidance and advice based on their answers, and then it aggregates data on patient outcomes for us.” (See sample form)

Dr. Hovanesian says using this program is advantageous for the practice in several ways: It helps to track whether patients are having complications; it collects surgical satisfaction data; and it aggregates outcome data that he can use to negotiate better contract terms. “We’re seeing 2- or 3-percent better reimbursement from carriers because we have these data to present when we negotiate our contracts,” he notes. “Most physicians do a good job, but they don’t have the numbers to prove that they’re doing a good job. With our very positive data in hand we can say to the insurance company, ‘We deserve not only to be on your panel, but to be on your panel as a preferred provider with better reimbursement.’ And we’re getting that.

“The bottom line is that you have to approach a negotiation with the idea that you’re selling something,” he concludes. “You’re selling yourself and your practice. Positive practice data will differentiate you from other companies that insurers contract with.”

Create a personal relationship with the insurance companies. Dr. Hovanesian says you’ll do better with any insurance company if someone in your practice develops a personal relationship with someone at the company. “You don’t build a relationship by just signing the contract the company sends you each year and returning it,” he says. “You build a relationship by having contacts at the company that your people talk to, not only about the details of your contract, but about individual patient cases. The people who get the best results from insurance companies are those who know the people at the insurance companies. They know just whom to call when there’s a problem; they know whom to call when there’s a contract issue.

“You can hire a consultant to be a personal contact for your practice, or you can have an internal full-time person serve this function if you’re a large enough practice,” he continues. “This is one reason that larger practices often do better dealing with insurance companies; they have the resources to devote to developing friendly, personal contacts at each company. A solo practitioner probably won’t be able to manage this; chances are it’ll be a lesser priority for an administrator.”

Fighting the Good Fight

 “I’m happy to fight a denial,” says Dr. Noecker. “I think that pushing back, standing up for yourself and your patient, is kind of a duty, and I think it does get results. I also think it’s just wise. Accepting denials can become a slippery slope. You may concede one point and then put the patient on a medication you didn’t want to use; then the patient has a bad reaction. In that situation, you’re the one on the hook, not the insurance company.

“I’d say I get what I want from insurers about 80 percent of the time, without doing too much work,” he adds. “My staff understands the protocol, and they take care of a lot of the process of asking the insurance company for what our patients need. Doctors have a tendency to just give up and do whatever the insurance company suggests, but at the end of the day, it’s on us to do what we think is right for the patient. There are ways to push back; you just have to take the time to do it.”  REVIEW

Dr. Hovanesian is a consultant for Omeros and a co-owner of MDbackline software. Dr. Noecker is a consultant for Allergan, Alcon, Santen, Shire and Glaukos. Dr. Packer consults for Bausch + Lomb and Alcon.

1. Parrish RK II. Visual impairment, visual functioning, and quality of life assessments in patients with glaucoma. Trans Am Ophth Soc 1996;94:919-1028.
2. Steinberg EP, Tielsch JM, et al. The VF-14, an index of functional impairment in patients with cataract. Arch Ophthalmol 1994;112:630-638.