Checking patient insurance eligibility and benefits remains essential to medical practice income and productivity.
You can perform eligibility checks several different ways, depending on the processes your office and insurance carrier use. But there are also a few important questions you should ask.
Ideally, new and returning patients bring their insurance identification card when they come to your practice. The staff person responsible for checking them in should then confirm with the insurance carrier that the information on the card is up-to-date and correct.
Often you can verity patient information by checking the website of the insurance carrier or by calling a representative directly. Some practice management software and clearinghouses also can check patient eligibility for you, saving staff time and effort.
A primary care provider generally wants to confirm that insurance is in effect at the time of service and figure out the amount the patient will need to pay (co-pay/co-insurance). A specialist, however, needs to check if the co-pay for a specialist visit differs from the co-pay for a primary care visit. A specialist also needs to verify if their services will need a referral or pre-authorization.
The physician, whether a primary care doctor or a specialist, also needs to know if the insurer considers them an in-network or out-of-network provider. The benefits generally differ between the two.
Providers seeing Medicare patients definitely need to check with the carrier before seeing the patient. Coverage with a Medicare Managed Care Plan can easily confuse patients. Some Medicare patients will tell you that they have Medicare and show you their Medicare ID cards, not realizing that they enrolled in a Medicare Managed Care Plan.
Regardless of their plan, verify insurance coverage while a patient is in your office to avoid time-consuming claim payment delays from incorrect information.
For new patients, collect and verify insurance information when they make an appointment. This gives your office staff time to check the information in advance. If possible, let the patient know what they’re expected to pay to avoid any unhappy surprises.
Many factors go into figuring out the patient’s financial responsibility. Whether or not the provider is in-network, the type of provider and patient deductibles are just a few of these considerations.
Use a checklist like the one below to make sure your practice collects complete information at the time of the patient visit.
- Patient name
- Date of birth
- Address
- SS number
- Insurance carrier
- ID#
- Group #
- Insurer phone number
- Address for claims submission
Questions to remember include:
- Is authorization necessary?
- Is provider referral required?
- What is the patient deductible?
- Are you an in-network or out-of-network provider?
Want to be even more efficient? Electronic medical billing can also save your practice time and money when deployed correctly.
Medical billing experts Alice Scott and Michele Redmond contributed to this post.
