Health Plan Benefits
Covered benefits under commercial payers can vary from health plan to health plan as well as from group to group within a particular health plan. It is imperative to verify the specific benefits for each individual patient being considered for surgery.
Every patient (enrollee) is provided a certificate of coverage. In many cases, the agreement is between the patient's employer and health plan, assuming the patient is not self-employed.
The certificate of coverage outlines:
- Benefit terms
- Exclusions
- Co-payments
- Deductibles
- Out-of-pocket maximums
Coverage for services or supplies is provided only when services are furnished while the patient is enrolled and the coverage is active.
Verifying Benefit Eligibility
A good practice is to request a copy of the patient's health plan identification card during the initial visit and initiate a process to verify potential health insurance changes on subsequent visits.
The following are tips to proactively manage potential pitfalls due to benefit eligibility:
- Request health plan information at the time the patient schedules their initial visit. This provides additional time to verify eligibility and benefits prior to the patient's first appointment.
- Ask for the patient to provide a copy of their current insurance card at every visit.
- Obtain a copy of the patient's driver's license or other form of picture identification. Confirm that the patient receiving services is the individual covered by the health plan.
- Verify eligibility on a regular basis by initiating a process to capture this information either when scheduling an appointment or upon arriving at the clinic. Most health plans have online access to verify eligibility.
- Inform the patient of their co-payment, coinsurance, or deductible responsibilities prior to their visit.
- Collect co-payments, coinsurance, and deductibles at the time of the patient's visit and prior to providing services. Co-payments, deductibles, and coinsurance are all considered part of the payment you receive from the health plan. Failure to collect payment increases your expense to collect the amount due once the patient leaves the office.
- Identify the responsible health plan. In many instances, patients are issued health plan identification cards with multiple health plan logos. This is challenging as you may be unaware of which health plan contract is valid, which plan is responsible for payment or what prior authorization policies and procedures are applicable.
- Verify coverage for all health plans if a patient is covered by multiple health plans. Some patients covered by commercial health plans also have coverage under Medicare, Medicaid, or other commercial plans.
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Develop eligibility and benefit coverage policies in your practice. Policies should incorporate quality assurance procedures to minimize errors and maximize billing and collection processes, thereby optimizing reimbursement receivables.
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