Practice Management Alert

Hint: Make sure you check whether the plan is active.

Pocket these tips to make patient insurance verification and eligibility determination a breeze. Terry A. Fletcher, BS, CPC, CCC, CEMC, SCP-CA, ACS-CA, CCS-P, CCS, CMSCS, CMC, QMGC, QMCRC, QMPM, a healthcare coding and billing consultant based in Laguna Beach, California, suggests the following best practices.

1. Check to see whether the plan is active. This is especially important now that the Affordable Care Act (ACA) has gone through so many changes; a lot of the private plans available through the healthcare marketplace aren’t necessarily valid or active at this point, Fletcher notes.
2. Ask patient whether there have been any recent insurance changes or if there will be any changes in the near future.
3. Find out whether the patient has coverage from multiple insurance companies — and check whether the patient has updated their coordination of benefits with each payer.
4. If the patient is 65 or older, check whether they use Medicare. For example, some people are eligible for Medicare but still use a plan provided by an employer or are covered in other ways through private insurance.
5. Check whether the patient needs prior authorization or a referral for the specific service they’re seeking. Bonus tip: When you go through the effort to confirm these types of details with a particular payer, make a list, so you’re not verifying the same information over and over, Fletcher says. Most payers keep these policies for a while, and you can designate a person and timeline for checking the payer’s website and policies to see whether they’ve made any changes.
6. Understand if the patient’s coverage includes diagnostics, procedures, or both. This is especially important in situations involving newer technologies used in some procedures.
7. Check for benefit limits and frequency guidelines, as some plans have ceilings on costs or visits or services.
8. Know whether some services, such as services surrounding behavioral health, mental health, or substance abuse, have particular payer requirements.
9. Make sure patients know their responsibility for payment, especially for self-pay patients who require good faith estimates under the No Surprises Act.