Practice Management Alert

No surprise: Managing the details is everything.

You know that pursuing reimbursement for your office means navigating relationships with commercial carriers and government-provided insurance programs. You can make sure these interactions are less of a headache for everyone by nailing down your insurance verification process and making sure your staff know these key tips.

“As healthcare practices, we have to verify the patient’s coverage for any medical services they’re searching out, and, really, determine their responsibility for payments,” says 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.

Read on for three tips that will help ensure your practice is capturing all the necessary information, all the time.

Focus on the Details

The eligibility and benefit-verification process is how you confirm the coverage offered by a patient’s health plan, Fletcher says.

“We want to make sure we can keep our cashflows up because patients are kind of getting savvy about what they have to pay when services are in or out of network, so it’s important to go back and make sure you’re giving your staff tools and checklists, so they’re covering everything when they look at the patient’s responsibility and do the verifications,” she says.

For any verification, you need to have certain patient information at hand and also know what elements of service you are verifying. The patient information you need includes:

• Subscriber name and patient name, which may be different
• Patient’s relationship with subscriber
• Patient date of birth, gender, member number, group number, and name
• Plan type
• Coverage date or policy-effective date

The aspects or elements of the plan you need to verify include:

• Deductibles
• Copays
• Coinsurances
• Payable benefits
• Patient policy status
• Effective date
• Type of plan and coverage details
• Plan exclusions
• Claims mailing address (which may be different from verification address)
• Referral and preauthorization rules
• Limitations, like frequency of visits and lifetime limitations

You must train your staff to be efficient in this process, Fletcher says, because efficiency can help you reduce your rate of denials and keep your cashflow going.

Establish a Workflow Protocol

Make sure you’re checking patient insurance verification and eligibility at least 48 hours before the patient’s visit, Fletcher recommends. This leaves enough of a buffer for a staff member to contact the patient if they, say, need a referral, without totally compromising your practice’s calendar.

“It really helps to reduce claims rejections and denials,” Fletcher says.

Some insurance carriers may have an electronic interface online for verifying patient eligibility, and others may require a phone call, especially in situations needing clarification, Fletcher explains. Build time into your schedule for more time-intensive follow-ups like phone calls, so staff aren’t tempted to cut corners and possibly leave money on the table.

Top tip: Make sure you ask patients to update details about their primary care physician, Fletcher says, because this information may affect whether they need referrals — which may be particularly important if you work for a specialty office.

Timesaver: Many electronic health record (EHR) systems and revenue cycle management systems can check eligibility electronically, Fletcher notes. Check with your billing manager or administrator.

Even after you’ve done this background work, it’s still crucial to verify a patient’s insurance information directly. While practices used to ask patients to bring their insurance cards to their first appointments for a staff member to manually scan or copy, it’s much easier and more efficient now to gather information before the visit.

More information: Streamline your eligibility check process with the tips in “Follow These 9 Tips When Determining Patient Eligibility” on page 3.