Making Benefits Verification Better at Your Medical Practice

June 23, 2012

With so many variables, how many times should your medical practice staff call to obtain insurance benefits?

The staff you assign to verify your patients' insurance have a very important role to play in your private practice. They make executive decisions every day that can either ensure you will be paid appropriately for your services, or not be paid at all.

Say you have three other colleagues that work with you, and each of you see three to four patients per hour. In an 8-hour workday that's nearly 100 patients per day! The employees you have assigned to verify these patients' insurance hold not only the responsibility of obtaining the benefits prior to the patient arriving, but obtaining the correct benefits. It is neither as simple as getting on the computer and going to the insurance company's website to pull the benefits off of that, nor is it as simple to pick up the phone and go through the automated options or even speak with a customer service rep. Your staff has made an art at obtaining these benefits on the patient's behalf.

It is not unheard of that benefits are obtained three or more times within a short time period just to make certain the benefits are correct. Over time, your personnel know the best resource to go to initially based upon the insurance plan, and the really good personnel can get most of the way there just by looking at the insurance ID number, group, or plan on the insurance card. The most important role you can play in this is to provide your new staff or newly promoted staff to train with such an employee. There are so many details that go into verifying insurance, and the quicker you can train your staff and get up to speed, the quicker they can move through the verification process.

A good rule of thumb is to start verifying online. If the specific information is unavailable, then it's time to pick up the phone and call the insurance company. Most often, employees will be tempted to just use the automated system, due to lack of time. However, the automated system does not provide you with a representative's name, nor are those calls recorded. Both of these you will need if you need to appeal a denied claim. Once you have a representative on the phone, it is critical that you know what questions that need asking. These reps read very quickly through their screens assuming your staff is taking good notes. If you don't ask the specific question about procedures being covered, if there are any pre-existing conditions, or how specific CPT codes can be used together, not to mention separate deductibles or co-insurances. No website or automated center can provide this kind of detailed information.

Often, some of these representatives are either very new at their job and really don't understand the words that they are saying, or perhaps the call center is outsourced and in another country altogether. When asked complicated questions, they might just say what they think your personnel want to hear (it happens) or they click on the wrong macro and give your staff benefits that are totally unrelated to what you need. Your well-trained staff members will understand when to cut their losses, hang up, and call back a second time. All of this just to obtain the correct benefits for your patients.

It is also not unheard of that regardless if your staff obtained the incorrect benefits from one of the insurance company's customer service reps, the insurance company will still deny. If you have a great billing department, they will be all over that insurance company stating who gave the benefits (date and time), and please reconsider the claim. If you have a weak billing department, you are writing off a claim for no other reason than incorrect benefits were obtained.

So, the next time you hear your staff obtaining these benefits, thank them for their efforts. They are looking out for your business and your patients.

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