When working with commercial payors, if you are not a provider in their various networks, you never know what their coverage guidelines and fee schedules are. That is why an insurance verification process is essential. Most providers only use information gained for a specific patient and it goes into the file, never to be seen or reviewed again.

Wouldn’t it be nice to have a database of the guidelines, fee schedules, and idiosyncrasies of the many commercial insurers that you work with? You can, but “it ain’t gonna be easy.” The process will take a focused effort. However, if you remain persistent, the benefits will far outweigh the work.

The plan is to create a database that has general information regarding the commercial payors that you bill on a regular basis, but your company is not in their provider network. This database can then be placed on your network in a spreadsheet format for your intake, customer service, and billing personnel for easy access. If you do not have your office networked, this database can be printed off, put in an insurance binder, and given to your staff for easy reference.

Go back to basics and evaluate your current insurance verification form. Does it give you the information that will assist you in getting paid by the insurer—not only for current patients but for future patients?

Questions for Database Info

• Is a prior authorization required? If so, you will need to get the prior authorization number for the claim.
• Is this a rent-to-purchase or purchase-only item? Do you rent for 3 months and then go to purchase or do you rent until the equipment reaches purchase price? If it is a monthly rental, is monthly verification or pre-certification required?
• Is there a maintenance option for purchased equipment? (These rental and purchase questions are important, especially if you do a large volume of CPAP and bilevel business.)
• Is there any special documentation required other than the prescription? If yes, what is it?

To move faster, you can look at previous verification forms for the answers to questions that have already been asked. You most likely will find variations between plans within the payor’s portfolio.

While gaining the data from the insurance verification forms upon intake, go to your staff members who post insurance payments. Have them track the usual and customary fees on the top 20 products you provide. This will give you a good base, and you can see if the payments vary between plans or just on the “mood” of the payor. Track the payors for a period of 3 months and then take the data and place it in a spreadsheet that tells:

• If a prior authorization is required and how to get one. The medical documentation or billing department will need this information prior to processing the claim.
• Rental and purchase information that the billers use when sending out the claims for the appropriate charges.
• Maintenance information.
• Documentation that needs to be sent in with the claim. The medical documentation department should refer to this when gaining the proper information for billing.
• Fee schedule information. This should be placed in your fee schedule edits in your billing software for automatic contractual adjustments. Your intake/customer service personnel should refer to the database to see if you should accept the patient into services based on the profitability of the fee schedule.
• The number of patients that use your services that have a certain payor.

Once the database has been instituted, update as needed. Tracking this information will assist management in determining which payors to accept when patients walk through your doors or a referral calls.

When developing your payor contract marketing strategy, refer to the database to determine which payors you want to be a provider for. The database can also give you the number of patients that you currently serve. This information can assist you in stating your case that the payor’s insured relies on your services.

Compiling insurance data can offer enormous amounts of information regarding payors, and you won’t have to guess about reimbursement. Instead, you will now have some solid figures to use to your advantage.

Sarah Hanna is the vice president of ECS Billing & Consulting Inc, Tiffin, Ohio. She can be reached via email: sarahhanna@bright.net.