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How Verifying Patient Benefits Can Increase Revenue in 2014


With the Affordable Care Act will likely come increased patient copays, co-insurance, and deductibles. Here's how to understand what's coming and be proactive.

It is typical for the beginning of each calendar year to bring an increase in patient copays, co-insurance, and deductibles. However, with the implementation of the Affordable Care Act, 2014 will likely bring a larger increase than usual. Most of the insurance plans offered in the New York State Insurance Exchange, for example, have substantial deductibles, and none of them offer out-of-network benefits. And many of the patients enrolling in these plans have little to no knowledge of their coverage. Additionally, as providers, you may be unaware of which plans you participate with. It is possible to only participate with select plans offered by an insurer, so you may tell a patient you are participating with UnitedHealthcare, only to discover that you don’t participate with the UnitedHealthcare product they purchased on the exchange.

So what can you do to save time and avoid coverage problems? You need to be proactive. Start by logging into your state’s health insurance exchange and look at the plans that are offered. If you are not sure that you participate with a given plan, make a note of the specific plan or product name-ie. Empire Blue Cross Blue Shield Pathway Network-then contact your provider services representative to check if your tax ID or NPI is listed as participating for those specific plans or networks. Then check the benefits descriptions for each plan offered on the exchange, which will show a breakdown of applicable deductibles and non-covered services. Compile a cheat sheet for your front-desk staff, so when a new patient with a plan from the exchange calls you can quickly determine whether or not services are covered.

The insurance plans offered on the health exchanges are not the only ones you need to worry about. Small group and individual plans offered outside the health exchanges must also be compliant with the healthcare reform law by their renewal date, which is typically January 1, April 1, or July 1. Again, it is likely that copays will increase, and plans may be subject to a co-insurance or deductible for the first time. Patients may be unaware that their plan has changed, so they may get upset when they receive a bill. And unless you have a system in place to verify benefits and communicate the changes to the patient, you may lose money.

You may argue that it is the patient’s responsibility to understand their benefits, and that your office does not have the time and resources to verify each patient’s benefits; however, those arguments will not increase your revenue. Consider your understanding of your own insurance policy, and you can see that it is not black and white. Most patients receive little to no guidance regarding the specifics of their benefits, and they rarely expect to have separate benefits for office visits, procedures, radiology, and surgery. Despite that, many insurance plans pay office visits at 100 percent, and apply a deductible or co-insurance to in-office procedures or radiology; and the patients do not take responsibility when they receive a bill. For example, it is not uncommon for a patient to say that, had they known there was a deductible or co-insurance for a procedure, they would have refused it at the time of service. In that case, providers have few options. They can put the patient in collections, write off their balance as a courtesy, or give the patient a permanent spot on their accounts receivable report. Either way, they don’t get paid. Obviously if you want to get paid for every billable service you provide, the burden falls on your office to understand each patient’s benefits.

Commercial carriers offer a variety of online and telephone resources which give a basic description of covered services, including provider services lines, which allow you to speak with a person for detailed descriptions. And while verifying coverage can take time, it will increase competency and customer service which, in turn, will enhance your revenue and professional brand.

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