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.


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