Unless you’re a character in a teen movie from the ’90s, you probably don’t love hanging out on the phone all day. But even the average teenager would undoubtedly agree there’s a better way to spend your time than sitting on the phone with an insurance payer. I know—getting in touch with insurance payers can be a huge pain. Between scheduling, data entry, and collecting patient forms and payments, there’s not a whole lot of time for the insurance verification process. And being put on hold can bring workflow to a screeching halt. Worse yet, when things go wrong and claims come back denied, getting insurance reps on the phone—and getting information out of them—can be like pulling teeth.

But, as any seasoned billing veteran knows, failure to verify a patient’s insurance benefits can result in a denial, especially if the insurance is not active or the information on the insurance card is outdated. Even worse than that, if you hold a patient’s claims and ship them off in bulk—only to find out the insurance information is no longer valid—then you could end up with several denials. That means waiting even longer to receive a big chunk of change you’ve already earned. However, with the right preventative measures—and, of course, defensible documentation—you can ensure these oversights don’t spark a major revenue problem.

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Prevention Intervention

Though it’s often easier said than done, ideally, a patient’s insurance benefits should be verified before his or her initial visit. This not only ensures a great customer service experience on the patient’s end, but also prevents any “surprises” from cropping up later on down the line. While insurance companies aren’t always ready to give you all the information you need, you aren’t totally powerless. You can leverage your patients to get the most accurate data possible by adding precautionary steps to your intake process. In this blog post, private practice expert Tamara Suttle, M.Ed., LPC recommends creating a checklist to review with new patients via telephone before they have their initial visits.

This checklist includes insurance-related questions that will help expedite the payer outreach process. Examples include “What is the name of your insurance company?” and “What is your policy number?” Make sure the questions you ask require patients to have their insurance cards on hand.

You also can typically verify benefits online through the payer’s website. However, while verifying online is quick and easy, the information may be outdated or incomplete. So, while calling the payer may be more time-consuming, it allows you to perform a thorough benefits check by asking more targeted questions (e.g., “How many policy visits does the patient have left for the year?”; “Has the patient met his or her deductible?”; and “Is a physician referral required?”). Chances are, you won’t find that information on the payer’s website. Also, some of the more cutting-edge RCM systems on the market actually allow you to verify benefits with many insurance payers directly within the software application.

Initial Encounter Accountability

During last month’s webinar, WebPT president and co-founder Heidi Jannenga dispensed some sage advice for collecting patient payments in situations where you can’t verify the insurance info before the first visit: “I would collect a copay based on their insurance card,” she suggested. “Get a copy of that insurance card to make sure you have all of the valid information on that very first visit, and then immediately call [the payer].”

In the same session, Diane McCutcheon, president of Account Matters, recommended having patients verify their benefits themselves if you’re unable to do so. “You’re putting the responsibility in the patient’s hands,” McCutcheon said. “That way, if you don’t get paid for that first visit because you didn’t have an authorization, the patient can also take part of that responsibility on.” And realistically, patients should be verifying their own benefits anyway. This not only provides them with peace of mind—as they’ll know what they can expect to pay upfront—but also instills the understanding that benefit verification is a courtesy, and any amounts the clinic estimates may not be exact.

Worst-Case Scenario

It’s not always easy to wrestle information from a payer, but there are steps you can take to protect yourself in the event of a denial. As McCutcheon suggests, “The first thing you do when you call [the payer] is ask who you’re speaking with. You want to make sure you get their name.” According to McCutcheon, documenting every interaction can prove beneficial in the event of an appeal. She also stresses the importance of asking for—and logging—a reference number each time you call. And if you feel like you’re getting the runaround, “Sometimes you have to go up the ladder,” she said. “So if you don’t get an answer [from] the first [representative], ask if you can speak with a supervisor.” 

Ultimately, if you feel that a particular insurance payer—or a certain representative from the insurance company—has mishandled any facet of the claims process (including verification), you can file a complaint with your state’s insurance commissioner.

If talking to insurance payers leaves you feeling completely clueless when it comes to your patients’ benefits, don’t panic! There are ways to get the information you need. You can approach payers on all sides by using alternative methods of verification as well as putting some of the responsibility in your patients’ hands. And even if a communication breakdown leads to hiccups down the road, thorough documentation—and a little persistence—goes a long way toward ensuring your clinic gets paid.

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