What is patient eligibility?
Eligibility simply refers to a patient’s right to receive healthcare benefits. When you sign up for a new healthcare plan, you will be asked to provide information about yourself including your age, date of birth, current address, etc. Based on this information, your insurance company will determine your patient eligibility, that is, what healthcare services you are entitled to receive as a patient. If you are eligible for services, your insurance company will determine the amount of money you have to pay out of pocket for your healthcare services. If you are not eligible for services, you will not receive any healthcare coverage.
Eligibility for in-network services and providers
Every insurance plan offers a network of healthcare providers and services. This means that you will only be offered a selection of vetted healthcare providers, such as medical doctors, specialists, surgical facilities, and pharmacies nearby your home address. The network is made up of healthcare providers who have agreed to offer services to patients at a certain rate. This rate is often lower than the standard rates offered outside of a network. While in-network services and providers are provided at a lower rate, if you decide to visit an out-of-network provider you will have to pay the entire cost out of pocket. This is because your insurance company will not reimburse you for services you receive outside of your network.
Eligibility for out-of-network benefits
Some insurance plans will offer you out-of-network benefits even if you decide to visit an in-network provider. This means you will still be able to be reimbursed for services received at an out-of-network provider. However, you will pay a higher out-of-network fee than if you had received the service in-network. You will also have to submit a claim to your insurance company and wait for them to approve your claim before receiving reimbursement. Depending on your insurance plan, you might be allowed to visit an out-of-network provider after a certain period of time has passed. This is known as a “waiting period.” You will have to pay the full cost of the service out of pocket until your insurance company approves your claim.
Understanding your plan’s deductible
A deductible is the amount you have to pay out of pocket before your insurance company begins to reimburse you. As a patient, you will have to pay this amount every year before your insurance company will start paying you back. After you have paid your annual deductible, your insurance company will begin to reimburse you for any expenses you have incurred. Depending on your insurance plan, you might have multiple deductibles, that is, one for in-network and one for out-of-network services. With some insurance plans, after you have paid your deductible for in-network services, you will only pay a coinsurance rate for the remainder of the year. With others, you will continue to pay a coinsurance rate for out-of-network services.
Understanding your co-pays
A co-pay is the amount you have to pay for a specific service at the time of treatment. These services include visits to the doctor, medical tests, or prescriptions. Depending on your insurance plan, you might have to pay different co-pays for different services. Depending on what your insurance plan requires, you might have to pay a co-pay at the time of service or you might have to pay a co-pay at the end of the year. At the end of the year, you will have to pay the total amount of all the co-pays you have accrued over the course of the year.
Summary
When it comes to healthcare benefits and eligibility, the more you know, the better. Understanding your eligibility, what your plan offers, and how you can use it to your advantage is essential. It will also help you better understand what sort of healthcare options are available to you, how much they cost, and whether or not you qualify for certain services.
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]]>The law’s main premise is that a payer must reply to a valid claim within a certain amount of time (usually around 30 days for electronic claims).
In order to efficiently use the clean claim rule, your medical billing process must have a tracking system that flags:
- Which insurance firms are covered by your state’s clean claim statute (some are exempt)?
- The date on which your clinic submits each medical claim for the first time;
- Events that bring the clean claim clock to a halt (e.g., an information request from the payer),
- When your practice has responded to payer requests by taking action;
- The date on which you received the final adjudication decision from the payer.
The prospect of carefully tracking all of this data may seem intimidating, but with the right system architecture, it is both achievable and desirable. Your claims will pay faster after you file a few Clean Claim law violation reports. I’ve witnessed cases when payers have contacted solely to reassure the practitioner that claims will be processed swiftly.
Running a trial on a payer that frequently takes more than 30 days to adjudicate claims is one method to quickly get started using the clean claim law. Find a small number of significant claims for this payer that have been open for more than 30 days and run a test with them. This will enable you to understand the foundations of how to file, monitor, and view the results of complaints.
Tips for Getting Your Medical Practice to Have a 95% Clean Claims Rate
How can your medical practice attain a clean claims rate of 95%? Despite the fact that this may appear to be a tall goal, there are several medical billing tactics your medical practice may apply to help increase your clean claims rate – and your entire revenue cycle management!
Keep patient records up to date.
There’s a lot of patient information that can change—and change quickly—from contact information to insurance carriers and more. Patients must check or update their current information before getting treatment, as faulty patient data is a leading source of denied claims. To reduce delays, use exact documentation to help check patient information ahead of time, and have patients update their paperwork at every visit (or even sooner with automated reminders).
Prior to the date of service, double-check your eligibility.
Patients that come to your office on a regular basis are known as established patients. They’re also the patients who your employees might presume haven’t had any recent insurance changes. Most denied claims, however, are generally the result of outdated established patient insurance information. Collecting and confirming every patient’s primary, secondary, and even tertiary insurance at least five days before their scheduled service is one step toward a 95 percent clean claims rate.
It’s also vital to double-check any in- or out-of-network benefits, copays, or deductibles.
Keep in mind the deadlines for filing insurance claims.
In most cases, filing a claim necessitates submitting it within a specific time frame. Any claim submitted outside of the window will result in a higher number of refused claims.
If you want your practice to have a near-perfect clean claim ratio, one of the best ways to do so is to pay attention to claim deadlines and handle any concerns with patient coverage prior to their date of service so the claim is not submitted late. Aim for authorization between three and five days prior to service as a best practice.
Even the cleanest, most well-documented claim can often take weeks, if not months, to process. In the meantime, the practice loses out on revenue. This is why many of them opt to have their billing handled by a third party. Ultimately, WWS contributes to a smooth, continuous flow of revenue that benefits the bottom line of health practices. Contact WWS today to learn more.
]]>What is Medical Necessity?
The first thing you should familiarize yourself with is what criteria payors use to determine medical necessity. Medicare defines medical necessity as “Health care services or supplies needed to diagnose or treat an illness or injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”
To make this determination, claim adjusters should consider the following:
- Are the services based on credible, scientific evidence recognized by the medical community?
- Are the services clinically appropriate regarding type, frequency, and duration?
- Is the service effective for the illness it is treating and not more costly than an alternative service?
This criterion is subjective, and even if the treatment is pre-authorized, the insurance claim can still deny. This is why it is critical to keep thorough clinical notes and record of the patient’s experience throughout his or her time at the facility.
How to Appeal?
Before, you write an appeal letter, gather all of the information you have on the client. Review, the diagnosis, the treatment plan and authorization number that you agreed upon with the case manager, and any clinical notes you have during treatment.
Utilization Review
Utilization reviews bridge the gap between providers, payors and patients. They help ensure that the patient receives the appropriate level of care and that the insurance company will reimburse the provider for their care. Proper case management is critical to insurance reimbursement. This means comprehensive intake assessments, knowledge of the patient’s past and current mental state, and timely follow-up calls to extend treatment, if necessary.
Here are the 4 things you should know before calling for a Prior Authorization:
- Call in the case within 24 hours of admission.
- Gather all of the relevant medical necessity documentation during the intake assessment.
- Monitor the client’s progress and if they need more treatment, call in the request days in advance.
- Stay organized. Keep a record of details and any critical information from the case manager.
Familiarize yourself with the appeal process for the insurance company that you are submitting the appeal too. Similarly, you will also benefit from reviewing the patient’s specific policy, verifying there are not any written provisions that you may have missed during the VOB.
Writing the Appeal
Once you are familiar with the appeal process gather all of the information to support your case, so that you are almost ready to write an appeal. Your letter should be clear and concise, citing specific, evidence-based reasoning as to why the insurer should reconsider the claim.
At the top of the letter, include the client’s name, policy identification number, and the claim number that you are appealing. List the name of your facility and the NPI or Tax ID number. Attach any clinical notes and send the appeal using certified mail, fax or per the insurer’s guidelines.
Understanding medical necessity is an important part of medical billing because it is why an insurance company actually pays for a claim.
Stay connected with us to learn more about Medical Necessity to reverse a denied claims or Email me at support@wonderws.com
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