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Insurance Verification Errors

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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!  ;D

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

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