By Dina Brown, ANJC Director of Insurance & Government Affairs

The process of verifying a patient’s coverage—what the plan will cover, what the patient’s out-of-pocket expense will be, even as simple as whether the plan is in force at time of service—is a critical first step in revenue cycle management and is a valuable tool to create a better experience for your patients.

Verifying a patient’s benefits should happen prior to their first visit and at the beginning of each calendar year.

Patient’s plans can change from year to year, and while the patient may not be aware of a change in terms of coverage, these changes can alter your anticipated reimbursement, which can create friction with your patient/provider relationship and the financial stability of your practice.

The verification process benefits providers because it provides a roadmap for how you will collect your fees: what you can charge the patient if you are in-network, what the patient’s out-of-pocket will be if you are out of network, requirements for prior authorizations, confirmation of coordination of benefits if there is more than one plan and, most importantly, verify the policy is in force—and you have all the accurate information to properly bill in an efficient manner.

The verification process benefits the patient as well.

Verification allows the patient to understand their benefits, what their financial responsibility will be and allows them to plan, financially, for their care. This eliminates the stress of surprise billing and helps strengthen the patient/provider relationship by being transparent with the cost of the care prior to receiving it.

Some necessary steps in the insurance verification process include:

• Obtain patient demographics (name, date of birth, address, insurance provider, etc.).
• Copy both the front and back of the patient’s insurance card.
• Check the patient’s eligibility via the insurance carrier provider portal and through provider services customer service number to confirm there are no discrepancies.

Some information to identify during the eligibility check:

• Who is the policyholder?
• What is the policy effective date?
• Does the policy have a term date?
• If you are an in-network provider:
  • What is the copay?
• If you are an out-of-network provider:
  • What are the patient’s deductible and co-insurance?
• Is there a limit of coverage for chiropractic care?
  • Is it a combined total with PT, OT, in/out of network?
  • How many visits remain for the current year?
  • Does the plan require pre-authorization?

The verification process is a vital component to stabilizing your revenue and can provide better collections at the time of service, fewer contested bills, happier patients, and staff.

A little time devoted pre-service to the verification process can provide a smoother revenue cycle process.

ABOUT THE AUTHOR:

Dina Brown, MHA, LSSBB, is the ANJC Director of Insurance and Government Affairs. She has a master’s in health administration from The Edward J. Bloustein School of Planning and Public Policy of Rutgers University, is certified Lean Six Sigma, Black Belt, and has more than 25 years of practice management experience.