Let’s face it: many patients assume that if something isn’t covered by insurance, it probably isn’t important. And who can blame them? After years of navigating managed vision care plans and medical coverage confusion, they’ve been trained to see “covered” as synonymous with “necessary.” But as optometrists who diagnose and manage ocular disease every day, we know that the best care isn’t always pre-approved by a claims adjuster.
So how do we have these conversations without sounding like a salesperson? It starts with empathy, evidence, and a consistent practice-wide approach.
Insurance Doesn’t Equal Insight
When patients push back on out-of-pocket recommendations — whether it's a dry eye treatment, eyelid hygiene product, or an advanced diagnostic — the hesitation often stems from a belief that if insurance doesn't pay for it, it must not matter. My response?
I tell them the truth: insurance companies don’t always make decisions in your best medical interest — they make decisions based on cost. I might say, “This treatment is FDA-approved and effective, but your plan has decided to shift the cost to you — not because it doesn’t work, but because it saves them money.”
That simple truth reframes the situation. The treatment didn’t fail a clinical test — it just failed a financial one.
Value Through Personalization
Patients want to know why this particular option is right for them. That’s where testing comes in. I’ll often say:
“This test allows me to be specific about the type of intervention I recommend. Insurance may cover a medication that requires frequent use and may only address one cause of dry eye. But if that’s not your specific cause, it may not help. These tests help us pinpoint what will actually work for you.”
By shifting the focus to personalization — not just payment — patients begin to see the value.
The Role of Humor and Honesty
Some patients will ask, “Will this be covered in the future?” My honest (and slightly dry) response is: “I don’t see insurance companies covering more these days — only less.” They usually laugh — and nod in agreement. We’re on the same side. That moment of shared humor turns frustration into trust.
Let the Team Deliver the Dollars
I rarely talk costs directly — unless a patient asks me directly. That’s by design. I don’t quote lens prices, and I don’t quote procedure costs either. My job is to guide care decisions; my staff is trained to explain pricing and coverage with confidence and compassion.
That consistency keeps things clean. Patients don’t feel like I’m selling them something — they feel like they’re being helped by a team that knows what they’re doing.
A Framework for the Reluctant Colleague
When a colleague asks me, “How do I even start these conversations?” I tell them: think StoryBrand. The patient is the hero. You’re the guide. Their insurance plan is a confusing maze, and you’re here to help them get what they need.
Say something like:
“The good news is, your plans cover different types of things. Let’s look at what’s covered, and what isn’t — and then we’ll decide together what makes sense for your care.”
It’s not about pitching. It’s about positioning. When patients feel like you’re helping them navigate, rather than selling them something extra, the whole conversation shifts.
The Real Question
So when a patient asks, “If it’s not covered, do I really need it?” I respond with my own question:
“Do you want your care to be dictated by what’s cheapest for the insurance company — or what’s best for your eyes?”
They usually already know the answer.
About the Author: Dr. Christopher Wolfe is Chair of the AOA’s State Government Relations Committee and founder of EyeCode Education. A past Optometrist of the Year at both the state and national level, he is a fellow of the American Academy of Optometry and a Diplomate of the American Board of Optometry. Outside of work, he enjoys running and time with his wife, Jaime, and their nine children.
Thank you, Dr. Chris Wolfe, for sharing your insights. At Peeq Pro, we’re committed to helping practices simplify retail and strengthen patient care. Explore our resources and tools designed to make out-of-pocket conversations easier and more effective. Questions? Email us at info@getpeeq.com.