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Five Payer Pitfalls: Dealing with Patients and Their Insurance Plans


Being proactive with your patients and their insurance plans means you can better ensure your medical practice gets paid, no matter the circumstances.

We've talked about the necessary task of verifying insurance for your patients and how critical it has become to make sure you get the right benefits the first time. But, what happens when the benefits explained are not enough, or worse, the patient's insurance changes mid-treatment or has terminated? What is your recourse and plan of attack? Be proactive.

First, let's identify some areas that can be costly if not asked, obtained, and understood at the initial verification.

Patient's insurance plan does not cover the treatment or codes you plan to use
• In some cases, you will not know what you are going to bill to the insurance company until the patient arrives and is seen. However, you should have an idea based upon the initial phone call from the patient describing the problem. When your staff verifies the patients insurance, they can ask, “How is CPT Code 11111 paid? What if we also bill 22222, will you also cover that?” Sometimes when seeing a patient for the first time, insurances like Aetna only let you bill an evaluation code. Some HMOs also have this rule. Have a few options available for your staff to check on at the verification phone call.

Patient has a pre-existing condition rider on their policy not payable for one year to four years after obtaining the plan
• Face it, patients have no idea what is or is not covered under their plan. Most of them don't read the fine print. If the insurance plan is through their employer, most often no one is aware of the details of the plan unless there is a specific person in charge of understanding this and educating the employee. It's very important to ask the insurance company, “Are there any pre-existing conditions on the patients plan?” This is particularly critical if the patient is having some sort of procedure.

Patient needs pre-certification or authorization prior to treatment
• It's all about the game you have to play with the insurance company. You see the patient on good faith that the insurance company is going to pay. Technically, you are correct. However, if you want to lower your aging A/R and get paid within two weeks to 30 days, make sure your staff is asking if there is any pre-certification or authorization needed. Be certain the codes you want to use are on the authorization.

Now for two other scenarios:

You have a patient that is coming in for multiple visits, and the patient's insurance changes mid-treatment and they neglect to inform you of this change.
• Depending on how long the treatment goes on for, you certainly can make a point of re-verifying on a monthly basis. This might seem time-consuming, but you need to weigh what you will be paid for versus the 10 minutes it takes to perform this task.
• You can ask the patient at each visit if there was a change in their insurance while you are collecting their copay.
• When the situation comes up that they are unaware that their insurance has changed (happens often when through an employer) you will most likely receive a denial for that terminated insurance. This will immediately prompt you to call the patient and obtain the new insurance again calling on benefits asking about coding, pre-certification, and authorization. Sometimes, an insurance company will honor the treatment and continue to pay until the treatment has completed. This does not happen as much now as it did several years ago.

What if the patient has a COBRA plan that is not in pay yet or their insurance just terminates after you've done your due diligence and obtained the insurance benefits?
You have a few options here:
• You can wait it out until the patient obtains new insurance, but they will most likely not pay if the patient was seen prior to the installation of the plan.
• You can wait for the COBRA to go into effect. This may take 30 days to 60 days, and you have to hold all claims hoping there were no pre-certification needed on the plan.
• You can turn the patient into a cash-paying patient. This is probably your best option, and it should not affect your A/R in a negative manner. You have the option of using contracted insurance rates and using those as a guide for payment. This would mean you would charge the patient what the insurance would have paid, had it not terminated.

So overall, all is not lost, but take a few extra moments up front and asking the important questions is what will get you paid on time. Most often the insurance representative is reading a computer screen and does not really understand what they are telling your staff. To dig a little deeper has really become a requirement in insuring your successful payments and low A/R.

Find out more about P.J. Cloud-Moulds and our other Practice Notes bloggers.

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