Not verifying insurance benefits prior to rendering service can result in nonpayment, which affects your bottom line. Because this is a costly mistake that can be avoided, make it routine to verify eligibility prior to every patient visit.
Unless the patient has a medical emergency, there are four things to check when verifying eligibility:
- Coverage—Is the patient covered under the insurance carrier at the date of service?
- Benefit options—What is the patient liability for copays and coinsurance?
- Prior authorization requirements for drugs and infusions.
- Preexisting clauses—Especially important in case the patient has had a lapse in medical insurance coverage.
Consider the following examples, which are common occurrences in a rheumatology practice:
Example 1. A patient comes in for a scheduled infliximab infusion; it is the patient’s third time receiving the infusion. The clerk at the front desk does not call to verify eligibility or benefits because this is the patient’s third visit.
Do verify coverage because this is a costly service.
Don’t assume a visit or procedure is covered because it was approved in the past. There are several reasons why the current encounter would not be covered:
- The patient’s previous insurance coverage was cancelled and is covered under a new insurance carrier. In this case a new authorization is necessary.
- The patient’s employer could have changed the benefits package of the insurance coverage—not all employers change benefits packages at the beginning of the calendar year.
- A new policy has been made for the procedure that is being performed.
Example 2. A patient comes in for a scheduled visit to have an injection in the knee. The patient has been coming to the practice for two years. Upon arrival the clerk asks for the patient’s insurance card and then proceeds to contact the insurance carrier to verify eligibility and benefits. When the clerk contacts the insurance carrier that is listed on the card, he is informed that the patient no longer has coverage with that carrier.
Understanding Managed Care
The ACR’s The Business Side of Rheumatology has an entire chapter dedicated to understanding the managed-care environment and negotiating a profitable contract. Download your free copy at www.rheumatology.org/publications and refer to Chapter 8
This is a fairly common occurrence for Medicare patients who have switched managed care plans.
Do politely inform the patient what has occurred and inquire whether she has a new insurance carrier card. Because this is a new carrier, you must check the following:
- Confirm the patient is covered.
- Verify benefit levels.
- Ask about prior authorization requirements.
- Ask about preexisting clauses.
Don’t wait to verify eligibility. Call the new carrier immediately.
To improve your practice’s financial well-being and avoid costly mistakes, check, recheck, and then check again the insurance coverage of every patient before every visit. In some cases, such as with Medicare managed-care plan contracts, the physician must verify coverage. Otherwise, the patient is not liable if the services are not reimbursed by the plan.
If you have questions regarding eligibility requirements, contact the ACR’s practice management department at (404) 633-3777 or [email protected], or join the ACR coding list serve at www.rheumatology.org/membership and post your questions online.
Melesia Tillman, CPC-I, CRHC, CHA, is the coding specialist for the ACR.
