After a thorough insurance verification, make sure patients know their financial obligations. After that, it may be time to check your own liability insurance.

To ensure the survival of the health care provider, the collective effort needs to shift to the development of a rock-solid insurance verification process in addition to a comprehensive credit and collection policy with regard to patient-owed balances.

THE FIRST STEPS

Obtain accurate insurance information at order intake and conduct a quality insurance verification of benefits prior to dispensing equipment. Obtaining accurate insurance information may be difficult since you typically receive information from a physician's office or a hospital rather than speaking directly with patients. At a minimum, obtain the health plan name, phone number, patient identification number, and patient date of birth. Sometimes the group name, employer, or the name and date of birth of the insured are helpful.

Once this information has been obtained, contact the insurance carrier to verify the benefits. "Contact" may be offered via phone or online. Typically, a verbal verification will offer more details about coverage. However, an online verification could be adequate if you are a contracted provider or deal with the insurance carrier often and are clear on their normal guidelines.

An insurance verification can let you know some important facts about a patient's health care coverage, but you need to know the right information to look for. This process can be summarized into four sections: 1) information you need to provide to get the information needed; 2) gathering where/who you obtained the information from; 3) basic coverage guidelines; and 4) specific medical documentation requirements.

To get the information, be prepared with your provider number or tax identification number because this identifies you to the insurance carrier and will be crucial in knowing if you are an in- or out-of-network provider. You also will need to provide the patient name, Social Security number, date of birth, and identification number. This information allows you and the insurance carrier to ensure you are obtaining benefits on the correct individual. Sometimes you may need the group number, employer, and/or insured person's information.

Be sure to document basic information about who is providing you with the information, including their name and phone number. Also, document the name of the insurance company and the claims filing address to ensure you submit the claim to the correct location. Be certain you know what you are verifying benefits for. Ask for verification of the procedure code and/or description of the item ordered—and for the patient's diagnosis.

BASIC COVERAGE GUIDELINES

Make sure you inquire about the effective date of the policy to determine whether patients have coverage for your dates of service. Next, establish whether you are an in- or out-of-network provider and obtain benefits information for both if you are out of network. Depending on the person you are speaking with, they may elect to only give you the benefits that correspond to your relationship with the health plan. If so, try to persuade the representative to give you this information. It will be valuable in the decision-making process because you will have an idea of what to expect in reimbursement.

It is important to determine what the deductible amount is and if it has been met. It is equally essential to know what the co-payment and out-of-pocket amounts are, if any. Finally, ask what the claims filing time is. This allows you to know acceptable time frames for filing.

MEDICAL DOCUMENTATION REQUIREMENTS

Knowing if a certificate of medical necessity (CMN), letter of medical necessity, laboratory testing results, or other records are required gives you direction once the verification is complete. Also determine what, if any, prior authorization or authorization requirements the payor has and follow through on them. On the basis of this information, you can determine what documentation to obtain for timely reimbursement.

Once the insurance verification has been completed, or during the verification process, notes regarding your conversation should be recorded within your software system so that you have proof of the call. This can be valuable down the line if benefits were misquoted.

Although insurance carriers often let you know that verification is not a guarantee of benefits, there are laws to protect you against misquoted benefits. Your next step would be to contact the patient to discuss different options for service. If you are an out-of-network provider and were able to obtain in- and out-of-network benefits, share this information with patients and allow them to make an informed decision on selecting you as a provider.

Lisa Cusick

Depending on your company's policies, you may wish to match the in-network benefits—if you are out of network—to retain customers (if it makes sense financially). Most providers argue that referral sources will not use them unless providers are in an expansive network payor list. As a provider, let referral sources know you accept all orders, no matter the payor. This can be an appealing approach for referrals since you are offering them a one-stop shop to send all their patients.

Your credit and collection policy will assist you when speaking to patients to alert them to potential financial responsibilities. First, determine who is financially responsible for deductible payments and out of pocket expenses, especially when it is a high dollar amount. Financial responsibility could fall onto patients or their employers.

If the employer is liable, you need to obtain the appropriate contact information so you can set up payment arrangements for services prior to dispensing. Be sure to document this conversation or get a signed agreement specifying the terms of the arrangement. This should include the dollar amount of the payments, when to expect payment, and when the obligation will be paid in full. If the patient is liable, try to obtain payment in full prior to delivery. If the patient is not willing or able to do this, seriously consider if you can provide the service.

Lisa Bargmann

Consider setting up payment arrangements to have services paid for in an acceptable time frame. If you decide not to obtain a signed agreement, at least be sure to document the conversation within your notes system. Consider obtaining a credit card authorization so that you can make monthly automatic charges. This will alleviate the need for mailing invoices/statements and making phone calls.

While consistently mailing invoices and statements is necessary, take additional actions once due dates pass without payment—including phone contact. Since patients respond to different methods of communication, it is important to use phone calls to communicate the status of their account. Sometimes a simple reminder is necessary while other times there are unanswered questions about why they owe a balance.

Lisa Cusick is corporate manager of training and education with Bargmann Management LLC, and can be reached via e-mail: . She will present Understanding the Effects of the Insurance Industry on Your Bottom Line at Medtrade Spring, Las Vegas, on April 24, 2007, at 2:45 pm.

Lisa Bargmann is president and CEO of Bargmann Management LLC and Homecare Collection Service, and can be reached via e-mail: . She will present Optimizing Profits Through Best Practices at Medtrade Spring on April 26 at 8:30 am.