Insurance Benefits Verification

Obtaining the correct insurance benefits verification information is another very important factor in a medical biller being able to generate a “clean claim”. A “clean claim” simply means an insurance claim without errors. The receptionist/intake specialist must gather all of the necessary demographic information, including the patient’s complete insurance information before the patient is seen in the office.

Sometimes patients are not aware or forget the exact insurance coverage that they have or may not be familiar with their new insurance plan. For example, in regard to Medicare HMOs and Medicaid CMOs. The only thing the patient knows is that they have Medicare and/or Medicaid. Oftentimes they are not aware that they actually have a Medicare Advantage Plan or a Medicaid CMO plan. When the patient has a Medicare Advantage Plan, Medicare will send the patient a Medicare card and the Medicare Advantage card; so because of this the patient will sometimes assume that they have “traditional” Medicare (as primary payer) and a secondary payer/plan. This type of assumption causes a lot of headache and confusion later. More importantly, it will cause claim processing delays.

Another issue is when the patient retires or their group/employer health plan switches carriers and/or temporarily “suspends” their coverage. A patient will also sometimes forget to let the office know that their old insurance coverage terminated and that now they have a new insurance plan. Once again, if this information is assumed and not checked by the intake specialist, then this will also cause claim delays.

In this day and age, paper is out, and electronic documents are the norm. I understand the need and want to reduce as much paperwork as possible. However, when it comes to a patient's healthcare records and insurance information, it helps to have an actual copy of the insurance card instead of relying on the patient to “translate” their insurance information to you. By having a copy of the patient’s insurance card, then you can more easily confirm the correct policy and group number. The insurance card will also confirm the patient’s insurance company and on the back of the card, it will list exactly how and where to file the insurance claim, which is another important piece of information that is often entered incorrectly and causes claim delays.

The following are important items that need to be confirmed before the patient is seen:

1. Confirm that the patient’s name is entered on the insurance claim the same way as it is listed on their insurance card(s). Avoid nicknames because if the name doesn’t match what the insurance company has on file; they will deny the claim.

2. Verify that the policy is still active.

3. Depending on the physician/specialist/therapist and/or services being rendered, confirm

whether or not an authorization is required.

4. If the policyholder is not the patient, confirm the policyholder’s name, DOB and

address.

5. Verify benefit details that may be due at the time of service: copayment, co-insurance,

deductible, out-of-pocket and HRA/HSA.

6. Confirm where and how to file the claim.

7. If you spoke to a representative, write down the representative’s name and the call

reference number. If you used the automated system or website, at least write down the

date of your inquiry.

I also can provide the physician or therapist with a sample insurance verification form that can be utilized and customized by office staff to obtain the required benefit information mentioned above.