Commercial insurance plans and coverage issues change almost daily. Employers move from one carrier to another to find the most cost-effective plan for their company. A person may be on a PPO one year and an HMO the next. That is why completing a proper insurance verification is important. By taking the time to complete the verification prior to equipment delivery, you can lower your risk of denied claims and reduced cash flow.

However, completing an insurance verification takes time. Being placed on eternal hold or sent to the abyss of the touch-tone menu is unfortunately the norm. Even with all of the headaches involved, it is still the best place to start your reimbursement process. It will set the tone for your billing expectations and patient financial responsibility.

Obtain a front and back copy of the patient’s insurance card. In the event that the referral is a call-in, gain all pertinent information and record it on the verification form and delivery ticket. If available, the driver can confirm the information by looking at the card at the time of delivery.

Every organization should have some kind of form with preset questions for your employees to ask of the insurance company’s representative. Each question should be asked and answered. Occasionally, there will be questions that are not applicable and it should be noted on the form. The following is a list of some important questions to ask when verifying insurance benefits:

• What is the annual deductible? Has it been met? This will help you when figuring the amount the patient will owe your company.

• What is the percentage of coverage? Once again, you will know approximately the amount that will be the patient’s responsibility.

• What is the lifetime maximum on the policy? Has it been met? You need to know if their benefits are close to being used up.

• What is the type of insurance plan? HMO, PPO, or other?

• Is your company a contracted provider with this insurance plan? If you are, then you will need to refer to the contracted fee schedule.

• If you are not a contracted provider, what is the percentage paid to an out-of-network provider? Patients may not want to go with your company if they will be responsible for a higher co-pay.

• Is precertification required? If so, you will need to get the prior authorization number to put on the claim.

• Is this a rent-to-purchase or a purchase-only item? If it is a monthly rental, is monthly verification or precertification required?

• Is there a maintenance option for purchased equipment?

• Is there any special documentation required other than the prescription? If yes, what is it? Your billing department will need to gather all medical documentation prior to submitting the claim.

• Is a case manager involved? If yes, what is his or her name and telephone number? If yes, you may need to negotiate the price of the equipment directly with the case manager.

At the end of the conversation, always confirm the insurance company’s claims mailing address and get the name of the representative you spoke with. Document the date and time you spoke. Once this process has been completed, your intake person can better inform patients of their monetary responsibility and members of your reimbursement department will have the information they need to gain the documentation for clean claim processing.

Employee training on how to complete an insurance verification is important. If management shows it to be a priority, then your staff will buy into the concept as well. A sure way to fail or lead to incomplete verification forms is to just hand the form to your customer service staff and tell them to “do it.” The best way to train is to perform the call to the insurance company first and have your intake person observe, then switch roles.

After reviewing the process with employees, confirm that they feel comfortable in performing this responsibility. For those employees who have been doing verifications on a regular basis, audit their verification forms for complete and accurate information. Once a task becomes a habit, people tend to get careless and need to be redirected back to the proper way of performing the duty at hand. A word of caution: insurance verifications are one of the top responsibilities to be put on the back burner by customer service personnel. The reasons vary, but usually are due to:

• Time of the delivery. The referral is called in after the insurance company has closed, the call has come in after hours (or on a holiday) and the verification must be performed on the next business day.

• Time management by the intake department. The customer service representative has many paperwork responsibilities to perform prior to the delivery and to meet the delivery time frame; the verification gets put to the side with the intention of doing it at a later time.

• Getting through to the provider relations department. Insurance companies make it increasingly difficult for suppliers to gain the information needed to make a proper admission decision. The touch-tone menu and automated voice response make it difficult to actually speak with a “real” person. Most suppliers are pressed for time and sitting on hold for an hour does not seem productive.

From a marketing perspective, insurance verifications can assist your company in determining if you want to pursue contracts with the various payors in your service area. You can track the number of patients who are referred or walk in your doors with the same insurance plan. Some contracts are not worth exploring, while it may be in your company’s best interest to investigate others. Communication between your marketing and reimbursement departments is invaluable. The billing specialists can give input as to whether a certain plan is worth pursing. Once contracted, all claims and admission requirements must be reviewed with both the billing and customer service departments.

Another benefit of tracking insurance plans through verifications is that you can gain important data regarding fee schedules, medical documentation requirements, and coverage issues. If many of your patients have the same plan, your billing department can take the information from the verification forms and make “cheat sheets” that they can refer to when processing claims.

The path to a complete insurance verification is not always smooth. There can be many bumps along the way. Special circumstances such as after-hour or holiday deliveries can put the verification process on hold until the next business day. Your organization needs to address these issues and set up guidelines to limit the damage from a wrong decision to accept a patient into service. The time spent by your company to properly complete an insurance verification will result in lowered DSO and increased cash flow.

Sarah Hanna is vice president of ECS Billing & Consulting Inc, Tiffin and Dublin, Ohio. She can be reached via email: sarahhanna@bright.net   or through the Internet: www.ecsbilling.com.