Remember the game of telephone? Here’s how it goes: A group of kids sit in a circle, and then someone comes up with a message and whispers it to the person on his or her right. That person whispers what he or she heard to the next person, who then whispers it to the next person—and the message travels all the way around the circle until the last person announces what he or she heard. Somehow, almost every time, the message distorts until something like “Hockey is cool” turns into “Hog monkeys rule.”
It may sound a little silly, but getting correct patient insurance information can feel scarily similar to a game of telephone. A patient’s employer tells the patient about his or her insurance plan, the patient tells you, and then you use this info when you send a claim to the payer, except—whoops!—the information the payer has on file doesn’t match your records, and suddenly you’re in denial city. The best way to head off this high-stakes game of telephone is, quite simply, to immediately verify the information your patients give you. So, let’s run through how to check insurance benefits.
1. Collect the patient’s insurance information.
First things first: If you want to head denials off at the pass, you gotta get some information from the patient, ASAP. Insurance verification isn’t always smooth sailing, so you must allow yourself ample time to complete this process—which means asking new patients for their insurance information when they call to set up their first appointment. When you collect the patient’s insurance information, be sure you record:
- the patient’s name and date of birth,
- the name of the insurance company,
- the name of the primary insurance plan holder and his or her relationship to the patient,
- the patient’s policy number and group ID number (if applicable), and
- the insurance company’s phone number and address.
Don’t forget to ask about secondary insurance! If the patient holds other policies, then you’ll need to complete all of these steps for each one.
2. Contact the insurance company before the patient’s initial visit.
The bulk of the reason why you should start the verification process early is that it can take some time to complete this second step. We recommend initiating contact with payers at least 72 hours before a patient’s initial visit. This will ensure that you have all the information you need long before the patient walks through your doors.
Contact by Phone
The most common way to contact payers (and, incidentally, the most time-consuming) is over the phone. Just pull up the info you got from your patient, find the insurance carrier’s phone number, and dial away. Once you get someone on the phone, double check that you’re talking with a representative on the provider services line, as some payers have lines exclusively for hospital admissions or referrals. After you confirm you’re speaking with the right rep, this resource says you’ll have to provide some information about your practice to confirm that this is a HIPAA-secure exchange. Finally, the rep will ask you to provide some of the patient’s information (usually the patient's name, date of birth, and the policy number) so he or she can locate the correct policy.
If you’re having trouble getting a rep on the phone, try calling back at a different time of day or day of the week. The provider services line is just like any other customer help line out there; there will be busier hours (and even days) when more people tend to call in at the same time.
If you don’t like the idea of playing payer phone tag (totally fair), you can opt out of telecommunication altogether by seeking out the payer’s online eligibility-checking resources. There’s no golden standard with these resources—and you may have to scroll through searchable directories or submit question forms—but you should be able to find the information you need somewhere on the payer’s website. Here are some jumping off points for some common payers:
One caveat: Payer-supplied provider directories have been known to contain outdated information. This might not necessarily be the case for eligibility resources, but it doesn’t hurt to remain cautious and aware of the possibility.
3. Gather all the crucial benefits information.
Now that you have the payer rep on the line (or the eligibility information on the screen), it’s time to whip out your verification checklist and gather the must-know details that will help you side-step claim denials. Here’s a list of questions (compiled from lists found here, here, and here) you can ask that should cover most of the information you need to record:
- Can you confirm the patient’s policy and group number, the name of the policy holder, and the relationship of the policy holder to the patient?
- Can you confirm your claims address?
- Is this policy active, and if so, what is its end date?
- How many therapy visits does the patient have left this year?
- What is the patient’s copay and/or coinsurance?
- What is the patient's deductible?
- Do you require physician referrals, pre-authorizations, or certificates of medical necessity for reimbursement?
- Are there any coverage limitations or documentation requirements I need to be aware of?
- Is the therapist the patient plans to see in- or out-of-network?
Keep in mind, though, that this list isn’t necessarily the end-all, be-all of insurance verification questions. Perhaps questions have come up in your clinic in the past about a particular payer’s funky rule (e.g., does it apply to this specific policy?), and this is the perfect time to chase your answers!
Assuming that everything went swimmingly with your information gathering, you’re finished! At this point, you should know whether or not the new patient has a valid policy—along with a general estimate of how much the patient’s visit will cost. If you really want to hit your customer service out of the park, give the patient a call back to provide him or her a copay estimate; it’s a great way to earn some goodwill! When the patient finally does come in for his or her first appointment, ensure that you scan the patient’s insurance card (and a picture ID, if possible). If you ever need to confirm that patient’s logged policy information is accurate, you can immediately reference the scan—and you won’t have to bother the patient about it!
Bonus step: Reverify every month.
In a perfect world, patients would remember to tell you the moment their insurance changes. But patients have a lot on their plates too, and if their insurance plan is changing due to something like birth, adoption, marriage, divorce, or a change in employment, it might slip their mind to keep their therapist’s front office in the loop. As such, it’s a good idea to reverify your patients’ insurance plans on a regular basis—monthly, if possible.
The telephone game may be a fun way to teach kids to be wary of second- and third-hand information, but it’s no fun when poorly-remembered facts affect your work life. Insurance verification may be time-consuming and tedious, but it’s truly the best way to avoid major billing snafus.