Outpatient Facility Coding Alert

Question: A patient who is scheduled for surgery says she has new coverage, but hasn’t received an insurance identification card yet. How do we file a claim for her?

Georgia Subscriber

Answer: Ideally, when patients call to make appointments, you should have someone in your office confirm their insurance coverage and eligibility, especially if you know the patient is going to have new insurance.

Now is the time of year when benefits verification tends to be most useful. While verification is good practice all year long, January is the time when you’ll see more insurance changes -- including payer, benefit, and deductible/copay changes -- than at any other time during the year because most employers hold open enrollment in December.

Finding out about insurance changes before the appointment gives you time to check if you are a participating provider with the payer and verify coverage. If the patient doesn’t yet have an identification number with her new insurance company, ask for the name of the insurer and the policy number from the patient, or from the patient’s employer. Then, call the insurer and verify the coverage and the date of eligibility, and get the appropriate information to identify the patient on your claim.

Warning: The date of eligibility is an important question to ask the payer because many employers don’t make health insurance coverage immediately available to new workers. A patient with a new job and new insurance coverage may be in your office for a visit today, but his insurance isn’t effective for two months.

Alternative: Although verifying coverage in advance is preferable, many practices have patients confirm their insurance coverage and note any changes when they check in for their appointments. If you are unable to verify the insurance coverage, or you find that the patient is not eligible for coverage on the day of the visit, inform the patient of the problem and ask if he wants to reschedule the appointment (unless it’s an emergency visit). Otherwise, explain to the patient that the visit and services may not be covered, and that he must pay the bill himself. Have the patient sign a waiver stating that the services rendered that day may not be covered by the new insurance, and that he is financially responsible. Keep the signed waiver in the patient record.