Get All the Facts from Insurers When Verifying Patient Plans

March 30, 2013

Your medical practice staff must be able to stop and ask questions from payers on plan verification to improve your revenue and patient relations.

It happens every day: The employee you have hired to verify insurance for your patients is sometimes in "auto-pilot" mode and just writes down what the insurance representative is telling him. Those reps are typically in a rush and speak very quickly hoping your staff can keep up.

They speak quickly for several reasons:

1. They have had several cut backs in the live-person area and they are understaffed.

2. Perhaps they are on some sort of commission to take as many phone calls as possible, and are paid based upon that number.

3. They speak quickly in an effort to either confuse or intimidate a person who is less likely to question what they are being told.

4. They are reading a script/screen and even they do not understand what they are saying.

Regardless of the reason, it is imperative for your designated staff member to be able to stop the representative and ask questions. You are paying your employee to verify these benefits to make sure you are going to get paid for your services. This means, during that phone call, you need to glean as much information out of that representative, as possible.

Here are some areas to consider asking more questions, rather than less:

Coordination Of Benefits
If you hear this statement, this means the patient has more than one insurance plan. What? They only gave you one card? Perhaps they do not understand that being on their spouses plan and having their own insurance through their employer means they have two separate plans. Which one is primary and which is secondary? That's where the coordination of benefits comes in. In some cases, the patient is no longer employed, and their personal insurance has not yet been made aware of this. Then the spouses insurance would be primary. But it's all about what the insurance company has in their system. In this case, the patient would have to call the insurance company back themselves and let them know that they are no longer primary. If it is in the system and a claim comes through, it will be denied.

In/Out of Network
Does your staff know your insurance contracts so well that they know if you are an in- or out-of-network provider? They should; particularly if you are under an umbrella network like PTPN or PTP. They accept thousands of plans under those networks, so it's imperative your staff know if you are contracted with a specific insurance. Without looking at every contract, how can they tell? Ask the representative. Yes, they will most likely sigh in frustration that they have to take a few more minutes and move to a different screen, but you are saving yourself billing nightmares by asking. Here's how a typical conversation goes:

REP: "Are you in- or out-of-network with Aetna?"

EMPLOYEE: "I'm not sure, can you tell me?"

REP: "(sigh) Hold on, please. (pause) You are out of network. Do you want those benefits?"

EMPLOYEE: "Yes, that would be great, thank you."  

No reason your employee cannot turn that question back around and find out.

Medically Necessary

This is a great one that the insurance companies have been utilizing for years, and have most recently begun to capitalize financially on. The representative will say that the visit(s) are "medically necessary." But what does this actually mean? For years, physicians have been required to write additional documentation and provides labs, and reports and tests to show that some procedure was "medically necessary" for the patient's overall health.

Yes, they are still denied. Here's what they are not telling you: Sometimes there is a date range that the patient can be seen in between under a specific injury, illness, or diagnosis. Some plans will say, "60 consecutive days per injury or illness." Most won't be that forthcoming.

Say Mr. Smith comes in to see you and over the course of the next nine months, he needs to have several shots, a surgical procedure, and perhaps an expensive treatment after the procedure. If the insurance verification states, "medically necessary," you better get back on that phone and find out if there is a date range for the treatment, or Mr. Smith is going to end up with a large bill, or worse, you have to write it off. When you call back, you find that there is a six-month timeframe starting on his first visit of January 3, and it ends on July 3.Your treatment is going to go two month longer. Right away, you ask what the process is to extend this deadline. Get names, dates, and times that you have spoken with a representative. It's worth the few minutes to save thousands of dollars.

Overall, you just have to remember that you are looking out for your practice. If you don't like what a representative has told you and they even insist it is still correct, simply call back and ask someone else. It is always okay to question an insurance company whether that is online on their website or a live person.