Author Topic: Benefit verifications for whom?  (Read 587 times)

ste

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Benefit verifications for whom?
« on: October 02, 2016, 01:22:09 AM »
I include benefit verifications in an overall service package marketed to both individual providers and groups. Physicians, however, often practice at multiple places where I may bill at one location and not another. If I verify benefits for a patient whose treatment occurs at another location, then I need a policy to ensure that I am compensated for verifying those benefits. A contract amendment is being considered to remedy a current situation and/or may become included in future contracts with group providers reading as follows:
Benefit Verifications have always been, and will continue to be, a free service for those whose claims are submitted by my office. I'm also willing to extend the free service to 20% above new patient and new insurance claim submissions. This will allow a generous amount of no shows and no benefits to be included in the free service. Beginning December 1, 2016 a $5 surcharge will apply to benefit verifications above the 120% threshold amount.
For example, 108 benefit verifications were completed for Group X in September 2016 and 49 new patient and new insurance claims were submitted. Surcharge fee calculated as follows:
   49 NP & I claims + 20% = 59 FBV (free benefit verifications)
   108 BV - 59 FBV = 49 SBV (benefit verifications subject to surcharge)
   49 SBV X $5/ SBV = $245 benefit verification surcharge
In this case Group X would incur a $245 surcharge for 49 above threshold benefit verifications. However, since our contract stipulates a 60 day notice to any rate hike the benefit verification surcharge will not take effect until Dec. 2016.
My questions are:
Is it normal to submit claims for only 40% of those whose benefits have been verified? Even when greater than 90% have benefits?
Is a contract amendment an appropriate method to remedy the situation? It seems harsh. 

williamportor

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Re: Benefit verifications for whom?
« Reply #1 on: October 02, 2016, 11:10:05 AM »
JMHO...

Q: Is it normal to submit claims for only 40% of those whose benefits have been verified? Even when greater than 90% have benefits?
A: If this situation fits your business model and you're happy with the compensation for your time and effort spent, I wouldn't worry about what's "normal" The $ per hour of your time spent should be your primary concern. 

Q; Is a contract amendment an appropriate method to remedy the situation? It seems harsh.
A: If the current language in your service agreement is not clear on a remedy, then I would say yes, you need an amendment, it need not be harsh, but everyone needs to have a clear understanding of their responsibilities. 
« Last Edit: October 02, 2016, 11:35:45 AM by williamportor »