About Erika Regulsky

How important is patient eligibility verification?

Are patients aware of co-pays or what if the doctor asks his team to adjust the co-pays while billing?

What if they are not aware of deductibles?

Here are a few opinions of those in the healthcare industry

• Judi Birch a Risk Assessment Specialist, Certified Professional Coder from Pennsylvania says “ There are certain times that it is more important to verify eligibility. New patients, patients who have not been seen recently and at the beginning of each calendar year come to mind. My experience has been to always verify eligibility on Medicaid insurance since there can be changes at any time. Patients should be, and usually are, aware of co-payments. There are always those who act like they are unaware. A provider is technically breaching his contract with the insurance company when Co-pays are waived. When I have explained this to providers, they love it because they can “blame the insurance” when refusing to waive it. It has been a long time since I have seen a provider not expect payment of co-pay at time of service. Many make the patient reschedule, especially if they have a habit of showing up without payment. Deductibles-An excellent reason to verify eligibility! A good billing team will be willing to educate their customers about their individual plans. This takes a little extra time, but pays off with patients taking on responsibility because they have a better understanding of their policy.”

• Michelle Uhl a professional in Revenue cycle management/CPC from Maryland says “Co-pays must be collected they cannot by law be written off same goes for deductibles. That breaks the physician to insurance and patient to insurance contract.”

• Mary Strange a professional in Medical Practice & A/R Management from Kentucky says “Always, always verify eligibility is my motto. The more informed patients are about their benefits and financial responsibilities prior to services being rendered can decrease the patient’s concern about financial issues and allow the physician and the patient to focus on the care being provided. As a secondary benefit (because the care of the patient is the most important thing), it allows the practice to increase revenues and decrease A/R days by increased collections of deductibles, copays and co-insurance ahead of the services being performed and decreasing denials of claims after billing. Patients do appreciate being included in this process and it allows them to get well without the added worry of how to pay their bills if they know what to expect and if financial arrangements are made in advance of their services.”

• Inay Hernandez a Billing Specialist at Citrus Health Network, Inc from Florida says.”Checking patient eligibility is crucial. You should do it while you are scheduling an appointment, this way you are letting the patient know about deductibles and/or co-pays. When billing, if possible, check eligibility to avoid future denials for invalid member id#, DOB, policy termed, etc. Always pay special attention to TPLs (if billing Medicaid, Medicaid HMOs or MMAs)”

• Nikki Carlson a professional in Revenue Cycle/Practice Management, Medical Billing/Coding, Training & Development, Electronic Health Records from North Carolina says “Eligibility verification is very important. Revenue gets lost in a variety of ways, but front desk personnel not collecting the correct co-pay amount is a big one. For instance, a very large hospital/physician office system here in the Raleigh-Durham area has consistently asked me for my “$15 co-pay” (what it says on the card) when in reality my co-pay is $25. This indicates to me they are just looking at the card and not verifying benefits. Another scenario is with United Healthcare (and I’m sure other payers as well)…where they list a certain co-pay on the card, but it is not the “real” co-pay. UHC has a “premium provider” plan and if a patient sees the premium provider, they pay the co-pay amount listed in the card, however, if they see a non-premium provider (and that is way more common than the former), they pay a higher co-pay that is not seen on the card. The only providers who know about this little secret are generally the premium providers (and again, there aren’t many, at least not in my network/area), and the providers who check eligibility, and are aware of these co-pay rate fluctuations based on provider status with UHC.”

• Daniel Figueroa a CBCS, CICS, CPAT, CPB, CPC professional from Florida says “ Inspirational and Motivational Speaker, Trainer, Mentor, Support Manager, Leader, Medical Billing & Coding Professional: Checking eligibility is one of the most important roles in the medical practice, if not done correctly it will cause a domino effect in reimbursement, and attempting to collect monies owed and or additional information is time consuming. Its important to do it right in the beginning, Remember people change jobs often or lose their job due to financial situation in the company, so always ask if they are still insured with their current insurance carrier. Collect any co-pays and or co-insurance due to the practice so the patient does not have a running balance when they come to the office again. Always verify if its an injury or illness, so you can bill the proper insurance carrier; example workers comp/auto/liability etc.”

• Mary Stark an Administrative Assistant Customer Service at Casey’s Cookies from Florida says “Patient eligibility is very important. If the patient’s benefits have expired, you can contact them to make the patient aware. Some patients are aware of co-pays while others have to have them explained. The doctor & his team could adjust the co-pays while billing but many insurance companies have banned waiving write offs because of lawsuits, jail etc .The deductible is an amount that gets paid throughout the year.”

• Jennifer Bevak a Student at Ultimate Medical Academy from Pennsylvania says “Checking patient information at the beginning of the registration is very important. This is where you explain to the patient that they have co-pay, and to see if their medicare deductible has been met. This also gives the patient a chance to ask any questions about their insurance they do not understand and you can explain to them, they also have the chance to ask questions about the practice. This is very important to make sure you gather all the information from the patient so that you can check eligibility because if there is a problem, you can let the patient know and then all the concerns can be taken care of right then and there.”

• Doreen Boivi an owner at Chiro Practice, Inc from Portland says “ Simply said and to repeat – It is important to verify eligibility. New patients, patients who have not been seen recently and at the beginning of each calendar year. My experience has been to always verify eligibility. This will plug up a huge hole in revenue for over the counter collections.”

• Maureen Landry a Patient Account Representative III at Novant Health from North Carolina says “Verifying benefits is very important. And it needs to be done before Every visit. People change jobs all the time and just because they came in last month with say “Cigna”, does not mean they have Cigna today. My motto is to verify eligibility/benefits Every time they come in for services. Not doing that can make or break a practice. Oh ya, writing off co-pays is a breech of contract and it is illegal. Whoever does that, better hope they are not audited. 🙁 Remember, Medicare is planning on paying for services for the next 10 years by auditing and taking back all monies that should not have been paid. How long before the other insurance companies do the same????”

• Virginia Vickie Rocha Ortega who works at Medical Billing Healthcare from California says “Very very important to the claim billing process Timeliness. Clean claim submission. Prompt payment process keeps from billing incorrect ins companies that could hold claims rejects from piling a backlog in laisun paid.”

• Monica Sanchez, an MBA, RHIA, CCS, ICD-10 Senior Consultant at MonuMed Revenue Solutions from Texas says “The belief that verifying eligibility is not important can have negative impact on your cash flow. Patients put the responsibility on the doctor offices to ask for the appropriate payment upfront. Let’s face it; many patients are not benefits-literate. They just accept what the front office tells them. So, if the receptionist says they own $20, they pay. If she says they owe $0, even better. One thing patients will fight is when they get a bill for a payment that was never even attempted to collect due to the negligence of the office staff at the time services were rendered.”

• Jeaninee Gomersall an EHR Activation Specialist at University Hospitals of Cleveland from Ohio says “Eligibility should always be checked prior to an appointment. Co pays are often found in ID cards as well. Staff should be trained how to read eligibility responses and then ask for the appropriate co-pay at the time of service. Co pays are due up front. Shouldn’t have to spend any more money to collect them.”

• Phyllis Cupil a medical Records and Health Information Technology Professional from Illinois says”Medical biller/medical office specialists are required to let patients know about co pays before being seen by the doctor. write offs are allowed, but im not sure about how it works or how many annually.”
• Erika Regulsky a NextGen EHR consultant from Florida says “The healthcare landscape is constantly shifting and patient payment responsibilities have increased. A thorough insurance verification process is half the battle won. The cost of resubmitting claims is very expensive so it is essential that medical practices pay a lot more attention to their patient insurance verification process.”

These are the comments from healthcare professionals . Do you agree that a skilled and knowledgeable team can help you in reducing patient eligibility verification mistakes?