It is essential that every physician practice verify the insurance eligibility and benefits of patients before services are provided. There are many missed opportunities to secure income and reduce staff time when patient eligibility is not verified at the time of check in. Training staff to complete this task can help boost revenue at time of service and save time on the back end.
Perhaps it goes without saying, but to do the medical coding and billing of a claim well, you need to verify the patient’s plan and coverage for yourself. Why? You need to know not only the difference between the types of commercial providers, but also their network affiliations, kind of coverage, and more.
Office staff should confirm whether the patient’s plan will consider the specialist an in-network or out-of-network provider. This is vital, because it will affect who is responsible for the main part of the bill. The primary advantage of determining that the physician is an in-network provider is to allow the physician to receive a negotiated or discounted rate for the services, and the patient’s insurance generally picks up a larger portion of the bill. If the physician is an out-of-network provider, then the patient will need to pay their portion of the bill at the time of the visit.
Look at the Insurance Card:
How do you tell what kind of plan — a PPO network, a TPA, or a commercial payer — a patient has? Fortunately, a commercial insurance company that underwrites plans and administers those plans for the membership is usually easy to identify. Just look at the patient’s insurance card.
The card provides phone numbers for members and providers to call. By calling the appropriate number, you can get a summary of plan benefits. Most commercial payers also have websites that enrolled providers can use to verify benefits and eligibility.
One of the responsibilities of insurance companies is to identify their patients and provide a way for medical offices to verify patient insurance coverage. This means that you will never be without a way to verify insurance for your patients, unless it is after hours or on the weekend.
There are three main ways to verify coverage:
- Online – Using various Insurance company websites and internet payer portals we check patient coverage.
- Insurance Company Representative Call – If necessary calling an Insurance company representative will give us a more detailed benefits summary for certain payers when not available from either websites or Automated phone systems.
- Automated Voice system (IVR) – By calling Insurance companies directly an interactive voice response system will give the eligibility status.