Clarity and accuracy are crucial to success when communicating insurance verifications between companies and patients
Insurance verifications are critically important to being properly collected for practices. The details of the verification provide necessary information for our practices in terms of the patient’s individual policy benefits and limitations—the parameters that claims will be processed according to.
The value of the insurance verifications is often unrealized. However, in reality, it serves as somewhat of the “mortar to the brick” in terms of building and maintaining a thriving practice where insurance may be involved. The reason for this is that the insurance verification is a two-fold communications tool that is necessary to the practice for claims preparation and billing, as well as for practice-to-patient communications and disclosures.
Insurance verifications: a tool for patient communications
Insurance verification also serves as an invaluable tool for patient communications.
After all, it is the patient’s policy benefits and limitations that will help determine the patient’s financial obligation to your practice. Uncollected or incomplete insurance verifications limit your ability to communicate financial information to the patient. Not only can this become cumbersome to your over-the-counter collections and accounts receivable, but it also can hinder practice-patient relationships.
No one likes to receive a surprise invoice in the mail or to learn that, after care has been rendered and charges have been denied by insurance, the patient is responsible for more than originally communicated or should be self-pay altogether.
Breakdown of relationships or systems, when peeling back the layers to find out why, almost always involves an element of communication: miscommunication, insufficient communication or sometimes no communication at all. This holds true internally among team members and within business protocols, as well as externally between the practice and patient. That’s how important the insurance verifications are: It is the single source to be utilized by your practice to best ensure that all applicable people get the same message as it relates to parameters of coverage and patient responsibility.
EOBs & ERAs
A common challenge is that practices collect insurance verifications but discover upon receipt of processed remittances (EOBs/ERAs) that charges were not processed as expected. Could it be a payer error?
Sure, of course, a payer could have processed erroneously; in this event, your practice will have to contact the payer or resubmit the claim to identify the error and request correct reprocessing. However, in many cases, the processing surprise isn’t a matter of payer error, but rather a matter of insufficient verification information collected, resulting in a misunderstanding in billing and a miscommunication to the patient.
Let’s look at just a few common examples of issues that could occur, that you can now avoid by simply gathering additional information upon verifying benefits or communicating differently with your patients for those procedures for which there are no benefits:
- Chiropractic benefits are not always under the same set of benefits as therapies, X-rays and E/M (exams). In other words, patients may have a completely separate set of benefits as it relates to any of these categories. This also means there could be additional copays/co-insurances under these benefits.
- Annual maxes or other limitations may differ in these categories as well. Once a maximum benefit has been exhausted for a particular procedure, this becomes patient responsibility, while other types of procedures may still be covered, so long as all other policy guidelines are met.
- Payers may have additional requirements before coverage will be considered. This may include preauthorization requirements or other documents the practice must complete and return to the payer, such as Patient Summary Forms or Medical Necessity Review Forms. Your practice should confirm this information as well, because in the event that something of this nature is required for coverage, but not adhered to by the practice, your claim will be denied, and often times, patients may not be billed instead. This can become a very costly oversight.
Yet, even with having collected a detailed insurance verification, practices often find that entire claims or individual claim line items are denied with various explanations, and patient records or payer recoupments are often being requested. What could be the cause of this?
Communicate possible coverage issues
To shed some additional light on the question above, when you call to verify benefits, one of the first statements made by the claims rep is always, “This information is not a guarantee of coverage. Coverage will be determined once a claim is received and processed.” This very important statement is standard for a reason. And it should be communicated to your patients as well when you discuss financial details with them. You might even consider putting it as a first line in your financial policy documents or as the top line on your verification form if your practice provides a copy of this to patients.
There are a few reasons why this statement is so important:
- First, this is telling you that the claim is going to be reviewed to ensure it meets coding and billing guidelines, which includes procedure/supply codes (CPT/HCPCS), modifiers and sufficient diagnosis (ICD-10) to support necessity for treatment.
- Secondly, the claim is going to be processed according to the benefits and limitations as defined within the patient policy.
- And third, the claim is also going to be processed according to the provider’s network status along with the specific payer policy guidelines for your provider type.
Most importantly, coverage is only available for claims where all three of these criteria are properly met. Also, consider that, for every procedure rendered, you must have sufficient diagnosis to support the procedure. Remember, your procedure codes (CPT/HCPCS) say what you’re doing with the patient and the diagnosis codes explain why.
For example, if you are billing multiple therapies or multiple units of timed therapies, you must have adequate diagnosis for each procedure/unit rendered to support necessity and explain why those procedures are necessary for patient improvement. In other words, just because a particular procedure may be “covered” under a patient’s benefits, it doesn’t mean the procedure is eligible for coverage if your claim isn’t meeting payer policy requirements, such as properly representing/supporting medical necessity. To put it simply, claim forms communicate much more to payers than you might realize.
The two parts of the whole
An easy way to look at coverage and eligibility is that there are two parts to the whole. One, of course, is the patient policy itself, which includes benefits and limitations as it pertains to that specific patient. Next are the payer policy guidelines, which are in place and applicable to every specialty or type(s) of treatment, regardless of provider network status; however, for an in-network provider, additional components will often apply.
A payable claim must adhere to each of these two parts in order to be eligible for coverage. This is also what makes the provider’s documentation so important. In the event claims or charges come under question or scrutiny by a payer (when, not if), it is rarely because there is a question as to coverage under the patient policy. Rather, it is typically that there is a question of coverage due to claim detail, perhaps indicating that treatment rendered is outside of the specific payer policy guidelines for that provider type.
In addition to reviewing insurance verifications and patient communications protocols, practices should also annually review payer policy guidelines. Understanding how each of these two major parts of coverage and eligibility work together will help your practice communicate internally, communicate with patients and know which procedures are expected to be covered by insurance and which should be patient responsibility. Your collections and patient relationships may depend on it.
BRANDY BRIMHALL, CPC, CMCO, CCCPC, CPCO, CPMA, can be reached at sidecaredge.com, which can help with billing, business development, marketing or IT management — we become an extension of your team where you need it most. With more than 200 collective years of chiropractic business experience, SIDECAR is the trusted partner with the expertise you’ve been looking for.