Questions Your Billers Should Ask When Verifying Insurance

By Michael Carroll on May 23, 2018

According to Healthcare Finance, “eligibility expired” is one of the top five reasons medical claims are denied. Hospitals lose $262 billion per year on denied claims. Now, think about how much it costs for an employee to spend 10 minutes of their time verifying insurance. For front desk staff making $15 an hour, the practice will spend $2.50 for their 10 minutes of time. That’s well worth the thousands, or maybe millions, at stake if services are performed, but not paid. Eliminating this top reason for claims to be denied is critical to maintaining cash flow and reducing recovery costs. Although many denials are corrected and eventually paid, research from Modern Healthcare estimates it costs an average of $118 per claim to recoup those funds. Again, spending $2.50 of staff time up front is well worth the cost. However, adequately verifying insurance involves more than just checking to see if their insurance is still active.

5 Questions Your Billers Should Ask

  1. Does the patient have both vision and medical benefits? Ophthalmologists have the advantage of two insurance options, both vision and medical, available to patients. However, that advantage can also be a complication when not handled properly. First, the scheduler must ascertain the reason for the patient’s visit. Some visits may be denied by medical insurance but covered under vision insurance or vice versa. The reason for the visit will determine which coverage to file the claim under. So for new patients, it’s a good idea to verify both types of coverage for your records. However, depending on what they are coming in for, that specific coverage should be verified again for each visit, or at the very least on a monthly basis. This dynamic also requires proper documentation including medical history, eye symptoms, medications and presenting reasons for the visit. As noted above, taking the time to get it right the first time will prevent denials, delays in payment, staff time to correct the claim and damage to your revenue cycle.
  2. Does the plan require a referral and/or authorization? All specialists, including ophthalmologists, know their patients may need a referral from their primary care doctor in order to be treated. It’s critical to verify this before treatment. If a referral is necessary, be sure they are documented in the patient’s record. Documentation required can differ from carrier to carrier. In addition to verifying if a referral is needed, always be ready to show you did, in fact, receive a referral. Verifying referral documentation up front will also allow you to verify the co-pay for seeing a specialist. Inform the patient before the day they arrive of the amount they are responsible for, since often times it’s a different amount than they are used to paying at their primary care provider.
  3. Is the rendering provider a participating doctor/provider? Health plans will either not cover or only partially cover claims from a non-participating doctor or other care provider. Patients rely on practices to tell them if they are not a participating provider. Don’t assume because you used to be on a certain plan that you still are. Health insurance plans have become very complicated in recent years, with varying levels of coverage and participation. For example, if you treat a patient from ABC Company who has selected a specific plan, don’t assume all employees from that company have the same plan, even if it’s the same carrier. Doing so will result in surprise charges for the patient that they may not be willing to pay.
  4. Does the patient have out-of-network benefits? If you discover your practice is not a participating provider, verify what out-of-network benefits the plan includes. Giving this detailed information to the patient well in advance of the visit will help them make an informed decision and prevent a last-minute cancellation which is likely to occur if they do not know the practice is out-of-network until they arrive.
  5. What is the patient’s deductible and has it been met? The CDC reports that nearly 40% of Americans are on high-deductible health plans (HDHP) now. Additionally, 15.5% of people on HDHPs reported having trouble paying medical bills compared to 10.3% of adults on traditional plans. Verifying what the deductible is and how much has been used will help your patients make an informed decision and prepare for the payment due. This once again emphasizes the importance of verifying insurance well in advance of the visit, preferably shortly after the appointment is made. Learning that they are responsible for the whole cost of the visit on the appointment day will likely result in them not paying that day. Be proactive. Build a reputation as a trusted resource for your patients.

Verify Every Patient on Every Visit

We’ve emphasized the importance of verifying insurance well in advance. That way you and your patients are equipped with the knowledge needed to treat and collect payment. However, don’t neglect verifying once more the day of the visit. The health care arena is changing fast. Economic hardship or the loss of a job may cause patients to lose their coverage between the time the appointment was set and when it actually occurs. They may simply have changed jobs, requiring an insurance change. Don’t get complacent and assume that just because a patient has seen you multiple times their coverage is the same. In addition, have copies of the patient’s identification and insurance cards on file. Having them stored electronically within your PM will enable you to reference them quickly when verifying insurance.

Script It

Make it easy for staff verifying insurance. Have a script that outlines the questions above plus any additional ones that might be appropriate for your practice. You might want to add the following:

  • What is the reimbursable amount for the service or treatment the patient requires?
  • Is this exam limited to a certain number of times within a calendar year?
  • Is the treatment limited to a specific number of sessions? If so, how many are left for this year?
  • Are there any diagnoses, treatments or services not covered?

Tracking patient coverage, submitting claims, storing important documentation and keeping a close eye on your revenue cycle are made much easier with a professional billing partner – like Agnite Health LLC, an affiliate of Advantage Administration, Inc. Ophthalmology billing, including insurance accounts receivable, is our main focus. Contact us to learn more about how our solutions can help your office run more efficiently.