Insurance Verification Errors

[billingfromhome428]

I have a situation in one of my client's ofc where benefits were called for a Medicare Advantage plan.  The ins rep gave the benefits as covering not only manipualtions, but also PT, massage, etc.  Obviously, MA plans don't cover these charges, but the ofc girl that called just thought "Wow, this is great insurance".  SO the charges were billed and rolled to the patient and the ofc is saying "But we called and got benefits and they said it was covered" and the ins says "Yes, they have PT, etc benefits, but only if billed by a PT, not a DC so we didn't give incorrect info, you just didn't ask the right questions". 

So that's the background for our patient that now has a significant balance and the doc isn't sure what we should do regarding writing the balance off as our mistake or discounting the services.  I am on the fence with my inital reaction being - it's the patients responsiblitly to know theire coverage; then it is the ofc responsiblity to check into something that sounds too good to be true.

Any suggestions are appreciated!
Cara

[thatcuteblonde]

Hopefully you got the name of ther person who quoted the patient's benefits. You can try to appeal the denial asking them to reconsider based on the benefits quoted. If you specifically asked for chiro benefits, state that in your appeal. Also, you might want to look into whether you can bill the patient, especially without having notified them first that services wouldn't be covered. I'm not sure the regulations in your state but see if an ABN is necessary since it is a Medicare patient. Most patients don't know their insurance benefits, so assuming that they should and holding them responsible for an error made by you or Medicare isn't fair to them and could cost the doctor the patient.

[PMRNC]

If An ABN was required but not given you can't bill the patient. The doctor will lose money but the person verifying insurance should have known what to ask and have been properly trained in this area. Yes doctors will lose money from "mistakes" that's the way the cookie crumbles. A lot of offices give receptionists the task of verifying benefits and that could be a mistake. It's a good idea to have a consistent means of verifying benefits and eligibility. I used a pre-screening form and there were a few different types used for different situations.

Linda Walker
PMRNC
www.billerswebsite.com

[Pay_My_Claims]

*blink blink* Girl you know that's the key to a healthy reimbursement. Knowing how to verify the benefits! 

[PMRNC]

ABSOLUTELY.. it's step one to getting paid.. the person doing this job NEEDS to be well-versed in what's at stake. When I get a client that wants full practice management I include this service because I know it's vital to reimbursement. I prepare the staff with a "pre-screening" form with data they are to collect when they make the appointment and by the time the patient comes in, benefits are verified and the front office knows what to collect at the front desk.

Linda Walker
PMRNC
www.billerswebsite.com

[Pay_My_Claims]

ABSOLUTELY.. it's step one to getting paid.. the person doing this job NEEDS to be well-versed in what's at stake. When I get a client that wants full practice management I include this service because I know it's vital to reimbursement. I prepare the staff with a "pre-screening" form with data they are to collect when they make the appointment and by the time the patient comes in, benefits are verified and the front office knows what to collect at the front desk.

Linda Walker
PMRNC
www.billerswebsite.com

Yes, and there is no one form that can do it all. I designed verification forms according to the specialty. Different questions apply to different scenarios!

[Michele]

I'm curious, if the girl wasn't told that they PT, massage, etc would be covered, would they have still been billed?  Also, when the eob came back, did it show them as Patient Responsiblity?

I agree with the other responses posted so I won't bother to reiterate.


Michele

[Amit_Nischal]

The only thing you can try to appeal the denial asking them to reconsider based on the benefits quoted. Also, it would be great, if you have insurance representives name . Simultaneously, you might want to look into whether you can bill the patient, especially without having notified them first that services wouldn't be covered and see if an ABN is necessary/signed by the patient or not.

Thanks,
Amikt

[PMRNC]

Insurance carriers always state that verification of benefits is NOT a promise of payment. It's also in each policy holders book and in every provider contract.

[Pay_My_Claims]

I had something similar happen, but it was on an inpatient basis. I documented everything, but then they tried to of course back up the employee. I told them I would have the client call regarding the matter....things changed shortly after that!!

[jcbilling]

Linda,

Besides the patient & subscriber's personal info, what do you include on the "pre-screening" form that is used to collect the patient data?

~ Charity

[PMRNC]

For my mental health providers I would have the office gather specific information such as asking them to look at the back of their card and read the name and phone number of the carrier for mental health and substance abuse. For other providers I would just make sure I got the name of the carrier, phone number and address for claims. At the top of the pre-screening form it had a blurb for the office to ask the patient if they had their insurance card handy and ask them to read right off the card.  This just gave us a jump start on benefit and eligibility checks.

[Pay_My_Claims]

For my mental health providers.

I like how you started that post, because there is no "standard" verification for medical billing. Each specialty will require different questions to ask. *thumbs up*

[PMRNC]

I agree, however I was talking about "pre-screening" which every practice could use to BOOST the effectiveness of the actual verification process. This is done when the patient first makes the appointment. It can also be called the initial intake. All of my clients utilize this and it's improved the verification process tremendously!

[Pay_My_Claims]

Oh....LOL well it was good anyway!