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Eligibility & Benefits Checking

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spectramedi:
Hi billing peeps,

Would like to know how you guys are checking the eligibility & benefits....

Our provider demands the below details to be checked before each appointment:
Whether provider is in-network, copay for specialist outpatient visit; deductible, how much met, if deductible applies to visit; and coinsurance

We do get the above exact details if we call up the insurance and choose to talk to an agent, which comes with the price of  looong call-waiting time and speaking time. But if we choose the option to get the benefit details faxed to save time or if we use the real-time eligibility checking feature, it won't provide all the the above details.
Most often it will just have the copay, general plan deductible, and coinsurance without mentioning if deductible applies to visits and even whether the provider is in network for this patient plan.


Is calling and confirming the only option? Any time-saving option is much appreciated.


Cheers!

Michele:
Usually the real-time eligibility feature has the information that a provider needs.  I'm confused as to why you need to check if the provider is in network for each patient.  Don't you know which plans they are in network with?    Also, usually if a patient has a copay then a deductible wouldn't apply and vice versa.  Is there a something unusual about the provider that complicates things?

PMRNC:

--- Quote --- I'm confused as to why you need to check if the provider is in network for each patient.  Don't you know which plans they are in network with?
--- End quote ---

Actually MY verification includes this question as well as it cuts down on the many conflicts carriers have with in/out of network so it's a great extra step and very pro-active. Especially if an ERISA policy where any and all benefits quoted can be used in an appeal.

I'd have to first ask.. what is in your contract? Mine includes full verification of benefits and eligibility and I provide all my clients with a pre-screening form they use when they make the appointment. I probably have a few more details I include such as, patient effective date, and if I'm verifyng benefits with seconday (yes I do this too) what COB model do they use, is their Pre-X (depending on the effective date). I think my process probally reduces denials tremendously and the pre-screening form I provide for my clients helps a lot as they only need to go down the list and obtain info I need.   I am probably a rare type in that I do NOT rely on onlin verifications at ALL.. it's much more proficient and time saving for the future to call the carrier and do these over the phone..then I can document who I spoke with, what they said and in many cases this is a plus if I need to appeal a claim.

spectramedi:
Thanks Michele.

Yes, Real time does provide the general info, but not always getting the benefits for the specific specialty and type of service.

Outlining the areas below where I find difficulty while checking real time or in faxed docs.
1) This provider's service is Specialist Outpatient Visit - I don't see "SPECIALIST" in real time or in faxed doc, but there is "PROFESSIONAL." Is both the same?

2) Sometimes there is no co-insurance mentioned.. in that case can we consider co-insurance as nil?

3) Does not mention whether deductible applies to the visits... okay, I noted your point "usually if a patient has a copay then a deductible wouldn't apply and vice versa".... is it always a confirmed rule?

4) Okay, why I need to check for each patient... coz sometimes it so happens that the provider is a participating provider with the insurance carrier, but for a particular patient' plan the provider might not be in network.

Thanks...

spectramedi:
Thanks Linda...

Agreement is that we provide the full E & B real-time checking feature in our RCM system for providers' use. (but this provider insists that we check and give her the results). Also, we wanna make sure the details obtained in real time and through on call are same... which as mentioned above is not quite happening, especially in the case of "Coinsurance," "Specialist" and "whether deductible applies to visit" and also "in-network confirmation for patient plan"

Thanks

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