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Keeping your team informed of administrative policies will help keep billing and collection errors in check.
We've all been there: Having one employee who asks every member of your staff the same question looking for a different answer. By keeping your staff up to date with the current practice policies, you will ensure there is no confusion, great communication, and a united front.
If you have an internal policy that states you cannot see patients that have exceeded their plan benefits for the year, it's something that must be enforced at all positions in your practice. However, there is often that one employee who feels sorry for the patient, and is willing to bypass your policy and get the patient in under their used-up benefits plan. When the plan is billed, the claims will be denied since the patient has already exceeded their annual benefit. When you try to turn around and bill the patient, the likelihood of actually collecting that money is slim to none. Patients really have an attitude of, "It's the cost of doing business. You took a gamble on my plan and failed. Not my problem." Now, you are out possibly several hundreds of dollars.
There are ways to avoid this type of scenario.
• Review your policies and procedures with your staff. All of them, including your billing staff. Have them "sign-off" stating they understand where the company stands on such scenarios.
Update your written office-payment policy that patients sign stating once insurance benefits have been exceeded, patients are welcome to come in on a cash basis.
• Be sure someone is reviewing all delays and denials as a form of monitoring. All staff need to be aware that someone is reviewing these items so that they are less likely to "let one slip through." Transparency and accountability are key.
• The staff member who calls on benefits should be trained to ask the question, "Is there any way we or the patient can appeal your decision to pre-deny this charge, or can we ask for pre-certification/authorization based upon medical necessity?" and "Can we send you chart notes, a prescription, and a letter stating how important it is for the patient to receive this treatment that will prevent further healthcare costs?"
A front-office staff member is likely to give in to a patient who is standing in front of her yelling up a storm and creating an unpleasant scene at the time of his visit. The best way to avoid this scenario is to call the patient ahead of time and let him know his plan will not be paying for the visit since his benefits have been exhausted. You can prompt the patient to call his plan directly, as you have no way of reversing the insurance company's decision. Dealing with an upset patient on the phone is a much easier experience to manage.
Patients really feel entitled to blame the physician and her staff for their plan benefits. They often think, "I pay my bill every month; the insurance should pay! Call them again!" It does not work that way, and patient re-education is critical in situations like this. If the patient claims to have called the insurance company and tells you, "They said it's okay to bill them," you will need some sort of reference number and authorization number in order to accept that. Do not just take the patient's word for it. They think we're all a bunch of bozos and we don't know what we are talking about.
It's your practice on the line, not the patients'. Protect yourself and be as proactive upfront as possible.