Medical Billing Forum

General Category => General Questions => Topic started by: spectramedi on January 25, 2018, 06:03:56 PM

Title: Eligibility & Benefits Checking
Post by: spectramedi on January 25, 2018, 06:03:56 PM
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!
Title: Re: Eligibility & Benefits Checking
Post by: Michele on January 25, 2018, 07:52:47 PM
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?
Title: Re: Eligibility & Benefits Checking
Post by: PMRNC on January 27, 2018, 03:08:31 AM
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?

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.

Title: Re: Eligibility & Benefits Checking
Post by: spectramedi on January 29, 2018, 04:41:58 AM
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...
Title: Re: Eligibility & Benefits Checking
Post by: spectramedi on January 29, 2018, 05:18:35 AM
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
Title: Re: Eligibility & Benefits Checking
Post by: PMRNC on January 29, 2018, 06:58:50 AM
Maybe asking how you charge in general is a better way to determine if you are being compensated for taking that extra step to verify benefits. As I said earlier, I do not use online verification because they are inefficient and incomplete for all the reasons and more than you stated. If you are charging a % of collections and your contract includes full practice management the verfiication of benefits should be done and should be complete as it is the very first and most crucial part of the biling process. That said if you are billing a % than I would say you should be doing these and if making the call is the way to get the proper and needed information you should do so. If you are charging any other way, look at your contract to see if your contract actually defines the services for full practice management. IF your contract is specific that it only includes the verification via the PM online verification system BUT it's not contributing to the proper reimbursement for your client you might want to modify the contract and include the extra step to call and adjust your charges to compensate for this service.

Online verification systems are ONLY good for checking eligibility, they ALL fail in that they do not provide the necessary information to determine many critical elements needed in case of an appeal. This is especially true for many specialties! 

Title: Re: Eligibility & Benefits Checking
Post by: spectramedi on January 29, 2018, 02:05:44 PM
Thanks Linda for such an elaborate explanation. Were thinking it's only us getting stuck on this :)

You clearly made some valid points on the compensation and contract side.

Thanks again.
Cheers!

Title: Re: Eligibility & Benefits Checking
Post by: spectramedi on January 30, 2018, 04:41:30 AM
Hi,

So is the "PROFESSIONAL" and "SPECIALIST" the same?

Our provider is a neurologist and wants the benefits for Specialist Outpatient visit... but when checking online or in faxed document there is no Neurology mentioned in the specialties and no Specialist Office Visit category... but there is a section for Professional (Physician) Visit - Office.

Thanks.
Title: Re: Eligibility & Benefits Checking
Post by: PMRNC on January 30, 2018, 05:06:14 AM
If there are no specialty's listed than it would be "professional". Depending on whether you are checking benefits for something in particular for example surgery, etc..that would be one reason you might want to call if there is no option for specific benefits. Again, since I don't do online benefits at all I am unsure, but most likely each carrier will have their own criteria to search by specialty/profession, benefits, etc.