Important Questions to Ask When Doing Verification of Benefits

One of the most common mistakes in medical billing is the failure of accurate verification of insurance claims. Insurance verification is the topmost significant step in the medical billing and coding process. Before you provide midwifery care to your clients, you have to verify if the patient’s healthcare benefits will cover up all the medical procedures needed. Presently, the healthcare industry continues to shift into many complex settings that require closer attention in validating insurance coverage, patient benefits, deductibles and copayments.
 
Every successful billing merely depends on the success of eligibility verification. In a brief summary, health insurance verification is the process of checking a patient’s active coverage with the insurance company. It also verifies the eligibility of a patient's insurance claims. Checking your patient's insurance benefits BEFORE the patient is seen should be a fundamental part of your practice's administrative process. Otherwise, you run the risk of claims being denied and left unpaid. You don't always have the right to appeal or bill your patient which is why it is so important to know the patient's insurance benefits before treatment begins.

When checking benefits, be sure to ask the right questions.
        1. What is the patient's financial responsibility?                                                

• Informing the patient of any co-pays, deductibles or coinsurance upfront will guarantee a better patient experience. Not only will the patient know what is expected from them financially, your front desk staff will also feel more confident when asking for payment at time of service.  This decreases the chance of a nagging patient balance and can reduce the number of patient statements that you need to send each month.
  
• Routinely checking benefits can also reduce the amount of refunds to the patient or insurance company due to over-payments.

        2. Does this patient have visit limits?

• Not all insurance plans offer unlimited visits to specialty healthcare services such as physical, occupational, and speech therapy.  This is why it is essential to ask this question when you call to check the patient's benefits. If the patient has a visit cap, what is the limit? How many visits have they already used for the year? These might seem like small details but they will play a huge role in reducing denials due to exceeding benefit maximums.
  

​          3. "Is this a plan year or calendar year?"

• Finding out if your patient's insurance plan operates under a calendar or plan year will benefit both the patient and your bottom line. This information lets the patient know when their benefits reset giving them a better understanding of their financial responsibilities.  And, having your front desk track and re-verify when benefits renew assures that there are benefits in place at time of service.  Keeping everyone informed and benefits up to date reduces frustration for all involved. 

          4. "Is a referral or authorization required?"

• Referral and authorization denials are two of the most common denial reasons. Finding out whether or not a referral or authorization is required BEFORE the patient is seen will have a huge impact on the number of denials your office receives. 
• It is important to note that denials due to "no auth" cannot be billed to the patient because it is not the patient's responsibility to obtain the authorization.  However, denials due to "no referral" can be billed to the patient because it is their responsibility to obtain a referral before receiving treatment. 

 
If your administrative process does not include checking patient benefits before the patient is seen, your revenue cycle management is hindered from the start. Accurate insurance verification ensures a higher number of clean claims which speeds up approval and results in a faster billing cycle. Inadequate verification of eligibility and plan-specific benefits puts healthcare organizations at risk for claim rejections, denials, and bad debt. Always pay attention to the documents submitted and be scrupulous in receiving the data needed for your service reimbursement.
 
Reference
Ramsey, D. (n.d.). The 5 most important questions to ask when checking benefits. Account Matters Blog. Retrieved August 5, 2022, from https://blog.accountmattersma.com/5-important-questions-to-ask-when-checking-benefits