One of the most critical (and most misunderstood) processes in an eye care practice is how to successfully pull medical benefits and identify eligibility. It sits at the intersection of clinical care, patient experience, staff responsibility, and financial sustainability. When done well, it enables accurate billing, reduces administrative drag, and builds trust with patients. When done poorly or inconsistently, it leads to claim denials, patient dissatisfaction, staff burnout, and lost revenue.

In the U.S., eye care practices operate within a hybrid model that blends private pay, managed vision care, and major medical insurance in various settings and clinical approaches. The clinical presentation of eye conditions can overlap between routine vision needs and medical diagnoses and will sometimes create confusion about which procedures should apply to which benefit, imperative that practices be prepared to bill appropriately in either situation. This preparation begins long before the patient sits in the exam chair.

In order to do this successfully, everyone in the practice needs to understand how insurance information is pulled, what information is necessary to do so, and which tools are at their disposal to get that job done effectively and efficiently. It requires that your team is well equipped to discuss these things with your patients in a way that instills confidence and a seamless experience. Your process must be tuned to fit your team, your tools, the kind of eye care you want to practice, and at the center of it all: your patients.

Ownership of the Process

In smaller practices, it is ideal for the owner to understand benefit verification and fee schedule management, even if tasks are delegated. This knowledge provides a backstop that protects the practice from payer misinformation, staff knowledge gaps, unnoticed revenue leaks throughout the process. As your practice grows, responsibility typically shifts to a billing manager, a practice administrator or another highly trusted internal leader.

If you, as the practice owner, have a lack of knowledge about it, it increases the likelihood that you will be taken advantage of by the insurance payors, by unscrupulous staff, or most likely by a poorly implemented process.

That's Shane Shepherd, Head of RCM at Anagram, and he's right. The stakes are real.

Regardless of role, ownership of this process should rest with someone who understands both the clinical and financial implications of doing this well, and by contrast what happens when this is poorly executed.

When benefits are pulled correctly, patients feel informed and respected, staff experience less stress and fewer confrontations, providers can focus on care (not billing drag), and practices collect what they are entitled to collect for services rendered.

Practices that struggle with either good execution of or getting started with medical billing often attribute the problem to complexity. In reality, the root cause is often insufficient preparation early in the process, and a lack of investment (both financial and in terms of time) in the continuous improvement of your team throughout the process.

Collecting Insurance Information

The benefits verification process begins at or even before appointment scheduling. Not at check-in and not after services are rendered. Collecting insurance information early allows the practice to work proactively rather than reactively.

In many eye care practices, appointments are scheduled days, weeks, and even a year in advance for practices that pre-appoint their patients. This lead time is a valuable operational window. When insurance information is collected at scheduling, staff can:

• Verify eligibility without disrupting patient flow
• Identify coverage limitations or exclusions
• Prepare accurate financial estimates
• Resolve demographic discrepancies before the visit

Practices are generally diligent about collecting vision plan information, perhaps because vision exams and managed vision care have been more or less inextricably linked for the better part of the last 30 years. However, many practices fail to collect medical insurance information at the same time, assuming it may not be needed or that patients don't want to share that information, or that it would be better to get that information once its necessity is clear. This assumption creates risk.

Successfully pulling benefits starts with getting the correct information as early in the process as possible; doing so will remove the pressure of having to do that when the patient comes in.

That's Shane Shepherd again, talking about something simple: front-load the work. Get the information early so you're not scrambling later.

Even visits scheduled as routine eye exams can uncover:

• Ocular disease
• Systemic disease manifestations
• Conditions requiring diagnostic testing or medical management

If medical insurance information is not collected in advance, staff are forced to scramble during the visit, increasing the likelihood of errors and patient dissatisfaction. Think about what that looks like in practice: the patient is sitting in the exam room, the doctor has just found something that requires medical billing, and now your front desk is calling back to the room asking for insurance information the patient may not have with them. It's disruptive to workflow, creates anxiety for the patient, and sets your team up for mistakes.

For practices with high walk-in volume, early collection may be more challenging, but the principle still applies: insurance information for every patient should be obtained as early as operationally possible.

What's Next

In Part 2, we'll dive into the specifics: what information you actually need to collect, why scanning insurance cards is non-negotiable, and how to overcome the biggest barrier to collecting medical insurance (staff discomfort in asking for it). We'll give you the exact language your team can use to ask with confidence.

Getting the foundation right sets everything else up for success.