February 11, 2013

We’ve all seen it. The patient comes to the check-in window, and you ask “Name… date of birth… have there been any changes in your address or insurance?” The patient quickly replies, “Nope”, and takes a seat in the waiting room. The charge is entered and billed to the insurance on file and two weeks later you receive notice from the insurance that the patient can’t be identified, or the policy has termed.

Avoiding this situation is all about asking the right questions to get the right information. This process begins prior to the patient waltzing through the front door.

Here are the 5 questions to ask, and when to ask them to reduce denied claims

1. “Is the patient eligible with this insurance?”

• The day before the patient’s scheduled appointment, call the insurance carrier on file and verify eligibility. Some patients are unaware of insurance changes and or policy cancellations and may be carrying around an old insurance card. Being able to inform them that they are not eligible with a particular insurance at the time of service allows them to prepare and provide you with the accurate information at the time of the visit.

2. “We have the patient id# as XYZ123456789, date of birth 01-03-1967, and the patient name spelled, J-O-H-N-A-T-H-A-N S-M-I-T-H, is that correct?”

• During the verification call to the insurance, if the insurance is active, verify that the id number, date of birth and patient name are correct. Patients frequently receive updated insurance cards that look very similar but contain new information that they may be unaware of, for example, a BCBS member may receive an updated insurance id card that has the same plan number, same policy number, but the 3-letter prefix may have changed. These slight changes are necessary when billing the insurance carrier.

3. “Does the patient have coverage for an outpatient preventative visit?”

• If the patient is scheduled for a specific procedure, check to make sure the patient has benefits to cover this procedure. Both the CPT code and the ICD-9 code are essential in making this determination. The patient may not have preventative benefits, therefore, anything billed with a preventative exam CPT (99391-99397) OR a preventative ICD-9 code (V-code) will not be covered and will be processed as patient responsibility.

4. “Does this procedure require any prior authorizations or referrals?”

• Also verify that the visit will not need any special prior authorizations or referrals. If the procedure being performed requires a referral, the referral will need to be obtained from the primary care provider. If a prior authorization is necessary it will need to be obtained prior to the patient being seen in order for the claim to process and payment to be received.

5. “Do you have a copy of your insurance card with you? May I make a copy for your file?”

• When the patient comes into the office to check in, request a copy of their current insurance card and ensure that it matches the information that has already been verified, if it does not match or the insurance on file was not active, begin the process again with this new information!

Asking these important questions can, not only help reduce denials for demographic issues, but can also help avoid billing patients for procedures that are deemed not a covered benefit by their insurance carrier. All in all, happier patients equal happier physicians!