Insurance Verification: A Thing of the Past?

Should you verify the patient’s insurance before the first visit? On the first visit? Before the Report of Findings (ROF)? Do you perform a Financial Report of Findings (FROF) first? Or do you submit the claim and wait for the Explanation of Benefits (EOB) to come. All of this uncertainty could be solved with a simple insurance verification.

With all the new-fangled eligibility tools available in portals, some practices have let Insurance Verification go the way of the Dodo Bird. But one single truth still stands…one of the key components of good management is to understand what assistance patients have with their financial responsibility.

We all know the call to the insurance company can be a very long and frustrating holding game.  We can probably recite their disclaimer regarding “this is not a guarantee of coverage…”  However, the information provided during the verification call regarding specific details of the plan, clarity on coverage limitations and exclusions, and accumulators is unmatched. The use of payer portals will only supply the patients’ eligibility status and leaves out many important details.

The Important Questions

Make sure that you get a quote on every procedure or modality performed in your office. At this stage, it doesn’t matter if the doctor is going to recommend them. An example would be orthotics for the patient.  It’s better to know the details of the patient’s coverage, rather than to have to call back again and again. (This doesn’t give you permission to find out what’s covered, and suddenly the patient needs that!) Dig deep into the benefits the best you can. Be thorough and probe further than the yes/no answers you may get from the representative. Some examples include:

• Is there a limit to the number of visits per year or condition? (Yes) What is it? (30 per year)
• Do you cover extraspinal manipulations? (Yes) If both a spinal and extraspinal adjustment is performed on the same day, do both count against that 30 visit limit? (Yes)

Say what!?? It’s true. Many offices don’t go on to ask that question. Sadly, they are disappointed when the patient is on visit 15 of an episode of care in which the patient had both a spinal and a knee condition being treated, and the denials pour in. By digging deeper into the questions, it’s possible to prevent heartburn later.

Patient Specific Information

Most patients want to know how much to budget for their care in your office. Many of them have a flat co-payment at their medical office and never see a bill beyond that co-payment. They may come to the chiropractor thinking that all insurance coverage is the same. If your practice accepts assignment for insurance payments, it’s best to be prepared with as much information as possible to help patients make financial decisions about their care.

Verification and eligibility checks should provide the amount of any annual deductible yet to be satisfied, patient responsibility in the form of co-payment or co-insurance percentages, excluded services, and whether any procedures require pre-authorization. Only then, by comparing patients’ estimated treatment plan with their coverage, can we  approximate their responsibility. Patients will appreciate having some idea of what accepting the doctor’s care recommendation will look like financially.

Verification: The Gift That Keeps Giving

Despite the disclaimer about a guarantee of coverage at the beginning of a verification call, there are steps you can take that can help if you have to file an appeal. Make sure to note the name of the person you spoke with ( first and last, if possible, or at least last initial) and the time and date of the call. Request that the confirmation is faxed or emailed to you. Since you can’t predict whether an appeal might one day be necessary, make these steps an automatic part of your process.

Insurance Verification is a simple step that provides a clear picture of who is responsible for what portion of patients’ charges and accomplishes the following:

• Contributes to a great patient relationship that fosters excellent patient compliance with your recommendations
• Makes it easy for the financial team to know what to accurately collect from the patient at each visit or on what payment schedule
• Enhances your billing team’s confidence that the billing to the insurance company is correct as well as the understanding of what can be expected from that carrier
• Helps your doctor know the best codes to utilize
• Clarifies what should be paid so that if a payment or EOB is different from what the verification stated, the staff member can confidently contact the carrier to inquire
• Increases patients’ likelihood to continue care since they know what to expect financially

Skipping insurance verification can have an enormous, negative effect on the financial health of the practice. On the other hand, obtaining a review of benefits before treatment can make a huge difference in your overall accounts receivable and improve patient confidence in the clinic.

Stop playing the waiting game and get proactive about insurance verifications. It’s a small step that can make a big difference to your bottom line.