When a scheduled patient walks into your office, staff members should already know whether or not this patient has the right coverage for their visit.
Your office staff should have already completed every task necessary to know this patient’s eligibility by verifying coverage and asking the right questions that will result in the knowing the details of the coverage. Being ignorant of your patient’s coverage can lead to shortchanging yourself for services rendered, which will not cover your overhead, or to overcharging your patients, which will set up a red flag with insurance carriers, eventually resulting in an audit.
Let’s begin with the patient information.
If the patient information that your staff retrieves is incorrect, you’re dead in the water before we even start. Even the incorrect spelling of the patient name can set you back a notch. Remember when John and Mark had one spelling. That same sentence can be written: Remember when Jon and Marc had the same spelling. See where it can get confusing for the person on the other end.
Having the correct address is just as important as having the correct name. Reviewing this information with the patient and comparing it to other medical documents are simple tasks that can save you a lot of grief.
Asking the right questions when calling about the patient’s insurance will help your office maximize its bottom line without jeopardizing the integrity of your business and setting yourself up for an audit.
- Does the patient you’re calling in reference to have the benefits to cover routine/annual visits, sick visits, and in-office procedures?
- Is there a co-pay? If so, how much?
- Is there a deductible? If so, how much, and what does it apply to?
- Has any part of that deductible been met already? If so, how much?
- Does the patient have co-insurance? If so, what does it cover, and what is the percentage?
- Does the patient have any out-of-pocket cost? If so, how much?
- Does the deductible apply to any of the out-of-pocket cost that the patient has the cover?
While the questions are important, it is just as important for whoever is asking the questions to know what these questions mean and why they are being asked.
- Does the employee know the difference between co-insurance and co-pay?
- Does your employee understand what the deductible is, and why it is so important to your bottom line?
The employee acquiring this information on your behalf should make themselves familiar with these terms and what they represent.
Co-Insurance, Co-Pay, and Deductible: Don’t confuse them!
- Co-insurance is the percentage of the contracted rate the patient must cover for their visit or procedure. This amount may vary, depending on the contracted amount the insurance company will cover for the procedure being done. For example, if the contracted amount for service is $100 and the co-insurance is 20 percent, the patient owes the facility $20 at time of service; the insurance carrier covers the remaining 80 percent.
- Co-pay is a set dollar amount the patient has to pay for their office visit. Some carriers have a co-pay of $20, $40, or even as high as $90. It simply depends of the insurance carrier and the details of the contract between the carrier and the patient.
- Deductible is a set dollar amount the patient is financially obligated to cover before the insurance carrier will start paying out their claims. For example, the patient might have a $2,000 deductible. It is the responsibility of your staff to find out if any of that deductible has already been met—before the patient walks through your door.
Imagine your staff allowing a high deductible-patient to slip through the cracks. You would have provided a service, for which you might never get paid. By the time the error is discovered, the patient may be so busy searching for the next doctor with staff members that do not know or care enough to collect money up front, the check to cover their bill to you will likely never see the inside of a mailbox.
Having the right information when your patient steps to the front desk and signs in for their visit can make or break your bottom line.
Minerva DeJesus and Audi Reyes are founders of Simple Solution Billing in Maitland, Fla.