Verifying Patient Health Benefits a Must at Your Medical Practice

Two dollars and fifty-five cents. That's how much it costs for an employee making $15 per hour, to take 10 minutes to perform an insurance verification. Can you afford $2.55 over the thousands of dollars you could stand to lose if something is not paid for because verification was not performed?

Risk versus reward - that is what it comes down to. Are you a gambling person? Do you just roll the dice in your practice when seeing patients? Of course you don't. Then, why allow your front office staff to do this for you? There are so many opportunities for denials when you do not spend the few minutes up front to get the information you need from an insurance company. Let's look at a few of them.

• Spelling of the patients name, and does it match the name on the card. As simple as this sounds, it is exceptionally important; particularly with Medicare patients. If the name does not match, the insurance company will deny it and state “patient not found.” That's about two weeks after the claim has been submitted. Do you bill daily? Weekly? Monthly? Look how that one simple step has aged your A/R.

• Has the date of birth been confirmed? Oftentimes, when new patients come in, they get the “white coats syndrome” and become very nervous. I have seen countless times their date of birth written on their documentation as 10/12/2012 instead of 10/12/1953. By not having the correct date of birth, you are not able to verify the patient's benefits. You see the patient anyway, and guess what …by the time your staff gets around to verifying, the patient is not covered for the service you just provided.

• Subscriber. This seems simple, but not all patients are subscribers on their own plan. It's not just children. Spouses often are covered under their spouse's plans, particularly with the TriCare/TriWest plans. You need to have the date of birth and SSN for the subscriber for those plans. The correct name and date of birth for any subscriber is critical.

• Policy number. When a patient calls in, and your staff member asks, “What is the number on the card?” there are several numbers to choose from. Most often, patients are in a hurry and just rattle one off. Sometimes it the correct policy number, sometimes it's the group number or claims code. If you are not verifying this up front, you could most certainly run into immediate denial.

• Deductible and Out-of pocket information. If your staff are not obtaining this information, how would you know how much to collect at the time of service? It is well documented that if you are not collecting the deductible, co-insurance, and co-pay at the time of service, you may never see that money. Yes, some insurance companies do not allow this, but there are few. Make a list. Collect the rest.

• Limitations or pre-existing conditions. If the plan states that a patient can only have something done once a year, follow that. Yes, the insurance companies are taking liberties that are not there's to take. If the patient needs a second appointment of the same type within the same calendar year, ask the patient to write a letter, then you'll write a letter of medical necessity, and send it to your billing department. The insurance company might make a consideration of payment if you show medical necessity. Otherwise, let the patient know they will be billed for the appointment. You are allowed to bill the patient what you would have been paid by the insurance company (had they paid). So instead of paying $165, the insurance would have paid you $92. That's what you can bill the patient as a professional courtesy.

• Claims Address. Sometimes with plans that have different medical groups, they want you to send the claims to an address that is not on the card. You would not know this unless you called. If you send it solely to the address on the card and it is incorrect, the insurance company takes 30 days to pay the claim, but you get a denial instead, you have aged out you’re a/R needlessly.

These are just a few areas to look at. Your practice could be very specialized and the questions you need to ask an insurance representative might be a lot more detailed. But the bottom line is to make sure your front office staff is carving out the necessary minutes it takes to verify a patient's insurance.

Don't gamble with your practice, and don't let your staff roll the dice on your behalf.