Checking Benefits & Eligibility on Patients

Whether you are working in a medical office or in a billing service you may be required to check with insurance carriers on eligibility or benefits on patients. Certainly in the medical office someone should be checking on the eligibility of each patient and what their benefits are or else that office is probably losing a lot of money. Some medical billing services offers this as part of their service. There are several ways this can be accomplished depending on insurance carrier and each individual office. And there are a few important questions to ask.
Generally when a new or returning patient comes to a medical provider they bring along their insurance identification card. The person responsible for checking them in should then check with the insurance carrier to insure the information on the card is up to date and correct. This can often be accomplished by checking the website of the insurance carrier or calling a representative of the insurance carrier. Some clearing houses are also capable of checking eligibility.
A primary care provider may be interested only in whether or not the insurance is in effect at the time of service and the patient’s responsibility whether it be copay or coinsurance for a primary care visit; where a specialist needs to check to see if the copay for a specialist is different from the copay of a primary care physician. A specialist also needs to verify if their services will require a referral or pre-authorization.
Providers seeing Medicare patients definitely need to check with the carrier prior to seeing the patient as coverage with a Medicare Managed Care Plan can be very confusing to the patients. Many Medicare patients will tell you that they have Medicare and show you their Medicare ID card and not realize that they are enrolled in a Medicare Managed Care Plan. You can save a lot of delays in getting your claims paid by checking while the patient is there to see if they gave you the correct insurance information.
Appointments for new patients are generally set up in advance and the insurance information should be collected then. This gives the office time to check the information prior to seeing the patient. It is important to know what the patient’s financial responsibility is before seeing the patient as it may be more than the patient expects and they may not be happy with a surprise. There are many things that can influence the patient’s responsibility such as whether or not the provider is in network, is the patient has a deductible and the type of provider providing the service.
It is best to have a form in front of you when checking for eligibility and benefits so you make sure you don’t forget an important piece of information. We have a form we have designed just for this purpose which you are welcome to download. This form can be stored in the patient’s file for future reference. You can download our benefits and eligibility form here.

Handling Denials for Duplicate Service

It is not unusual at all to receive a denial stating that the claim you sent is being denied as a duplicate but you have no record of receiving payment for that service. There are many reasons this can happen. Often billers don’t know what to do about such a denial. Here is what to consider.
First is the claim being billed by a billing service or in a medical office by the staff? In our situation as a billing service the first possibility is that the claim was processed but the eob was not passed on to the billing service so the claim was resubmitted.
The second claim was then denied as a duplicate. We have had situations where offices that didn’t realize they should forward an eob if a payment was not made. Sometimes it is just overlooked by the person in charge of forwarding payment notices. We have also had occasion when faxes failed or came through blank that were eobs.
The next possibility is that you have entered the claim twice in error. We have had offices send us duplicate dates of service and it go unnoticed and the claims were submitted on two separate billings. Our processors try to catch these, but occasionally one will slip through.
Another possibility is that the insurance carrier made an error. Every once in awhile we get an eob for a claim denied as a duplicate when it was only submitted once. Sometimes the claim will hit up against another claim for a different provider and a different service on the same date. It isn’t a true duplicate, but the computer system thought it was and denied it automatically.
So the obvious question is how do you handle each of these possibilities. In the case of the claim being resubmitted by a billing service and denied as a duplicate, the first thing you should do is make sure the claim isn’t entered twice. In a situation where a patient comes in repeatedly as in the case of counseling or chiropractic, it is not uncommon for more than one date of service to go on a claim. You want to check any billings where multiple dates of service were sent in that time frame.
If it wasn’t, look to see if it was submitted twice and payment came in before the second submission was processed. In either of these situations, it truly is a duplicate and the claim was denied correctly. You don’t need to do anything except review your process to see if you could eliminate this in the future. If it does not appear to be previously paid then the best way to handle it is to check with the insurance carrier and find out what happened the first time the claim was processed. When was it processed and what was the outcome?
If it was paid previously you should make sure the check was received and cashed by the provider. If it was and this is a common happening with this particular provider, you need to explain to them the importance of getting a copy of the eobs when they come in. It is a great waste of time to be tracking processed claims and a trigger for fraud with the insurance carriers.
If you find that you have submitted the claim on two separate billings and this has been happening frequently with a particular provider, you need to be more careful and check when entering new claims to see if these claims have already been submitted and find a system to prevent this duplicate billing. We have one mental health provider who faxes us and also mails to us. He often sends us claims in the mail that were previously faxes and already submitted. We now check all claims he sends to make sure we haven’t sent them already. We find this saves us a lot of work in the long run.
The important thing is that when you get a denial for duplicate claims, you have a system for handling it. You shouldn’t just assume that the denial is correct and ignore it. You need to investigate, determine if the claim was previously paid and paid correctly, and why the claim was resubmitted to avoid this in the future and to ensure your provider gets payment for all services.

Michele’s Thoughts on Tough Providers

Medical Billing can be a tough business. You can work your butt off, put your heart into it, do a great job and still fly under the radar – but not on purpose. Some providers don’t ever acknowledge you when you are doing a great job. Don’t get me wrong, it’s not all of them. There are always those very appreciative ones that praise you all the time and do recognize the work you do. They are gold. But there are the rest of the providers, the ones that no matter what you do will not give you any recognition. Never comment on the work you do, or show any signs of appreciation. And the minute anything at all goes wrong, whether it’s your fault or not, are right there to jump down your throat without even getting all the facts. Those providers can make this a tough business. Most people in the field of medical billing work long hours, and do everything they can for their providers to keep their accounts receivables running smoothly. When a problem arises they do all they can to rectify it, even if it takes extra hours. If the billing were being done in house, would their employees stay late for no pay?? I think not. These providers can sometimes discourage some to the point of giving it up. They throw in the towel because it’s just more than they can handle. I’ve been there. Never thrown in the towel, but certainly thought about it several times along the way. That’s where having a business partner comes in handy. When one of us wanted to quit, the other would pick up the slack. I guess my thoughts on this are that you need to toughen up a little, get a little bolder. Stand up to the provider and professionally give them the facts and let them know that you will do all that needs to be done but you won’t be treated disrespectfully. I tend to be way too sensitive and it bothers me when someone isn’t happy with me. I’ve had to toughen up. I sent a provider an email this week telling her she was very rude and I was blocking her from emailing me anything further. (We had given her a 30 day notice due to her rudeness, difficulty to work with, and erratic behavior.) Life is too short to work with or for providers that aren’t going to respect you and your work. But you can’t be overly sensitive either, so don’t go canning all your providers who’ve ever looked at you cross eyed! You just have to do your best in all you do, and be confident in yourself. Don’t let words by a provider upset you to the point that you give up what you want to be doing.