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Answering Insurance Questions from Your Patients


Patients are in a panic over shifts in their insurance plans and looking to you for deciphering. Here's how to provide great customer service to assist them.

A majority of patients are in the dark about what is and is not covered on their healthcare plan. You really can't blame them since their plans most likely change on an annual basis. With the conversion of healthcare upon us, there are even more opportunities for confusion.

What is the best way to calm your patients, while providing the most updated information to them? There are a couple of different schools of thought with this question. You can tell the patient that they are solely responsible for their benefits and that they should know what is covered prior to coming to see you. However true this statement is, it's not very realistic for you or your patient. I think a better approach would be to call about patient benefits prior to their appointment, ask very specific questions about the benefits, how they are paid, what codes are covered and what is not. Ask if there is a timeframe on these benefits, or if they can only be seen for this diagnosis once or twice or more per year. Is that a calendar year, or is it a benefit year, etc? Get specific.

All of these questions need to be asked prior to the patient arriving for their visit. Once they are there for the visit, spending a few extra minutes with the patient and explaining their benefits is critical.

This should especially be done with Medicare patients and everything shifting with their plans. Most patients do not understand when they sign their Medicare benefits over to a Medicare Advantage plan. They think they have Medicare as a primary insurance and Blue Shield as a secondary, when in fact, Blue Shield is the Medicare Replacement Plan. Benefits under these replacement plans differ greatly even within an insurance company. Some have a $10 copay, and others have a $50 copay. Explaining this to the patient is so important. Healthcare costs are on the minds of many, and being up front and forthcoming alleviates an unneeded stress that goes along with an appointment.

There are several resources available for the patient to become well educated in their personal insurance plan. My first suggestion would be for the patient to sign up with their insurance company through the personal website portal. Most all plans have this available to patients so that they can review pertinent information like: copay, coinsurance, deductible (what has been met, what is still pending to be met), how much of a certain benefit is still available such as number of visits with physical therapy, speech or occupational therapy benefits, etc.

The websites are also becoming more dynamic and "smarter," allowing the patient to figure out what the cost of a test or procedure will be prior to having that done. Involving the patient in their overall health, and empowering them to make decisions will take a burden off of you and educate them. Many insurance companies offer programs at a discount even if they do not cover a specific benefit under the patients plan. There is a weight loss company that provides Aetna patients a nice discount for signing up with them. There are seminars that companies and other healthcare professionals put on, that can also benefit the patient.

With so many options available for patients to learn about their healthcare plans and benefits, it can be as simple as steering them in the right direction. Again, you are not required to educate patients on their health plans or benefits, but what you would be providing is a level of customer service that is becoming near non-existent in this era. You are also working with the patient and not talking at them. People respect that.

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