Key holes to plug in the verification process

Steps you can take to avoid unpaid bills

Incorrect information about insurance eligibility is one of the most common reasons a practice does not get paid for properly treating a patient. Using incorrect information means the insurer will return your claims — or the HMO will refuse to include them under the cap payment — as unpayable because patients were not members at time of treatment or the services provided were not included in patients’ coverage.

"Every time a payer rejects a claim for ineligibility, your practice is not only inconvenienced, but also shortchanged," says Joan M. Roediger, an attorney with Health Care Law Associates of Plymouth Meeting, PA. "When this happens, practices are forced to act as bill collectors and track down payments from their patients, provided their contract even permits them to do that."

When you think about it, insurance eligibility mistakes are relatively easy to make. "Before the practice is notified about a change in someone’s eligibility status, the enrollee’s employer must notify the HMO or health plan, which in turn must notify you," notes Roediger.

However, some employers may not notify their health plans of benefit status changes for weeks, then the plan may not notify your office until weeks after receiving the information. Plus, patients who change jobs or health plans may fail to tell your staff.

"During this time, your practice could be providing significant amounts of medical services to plan beneficiaries who are no longer eligible to receive health plan benefits but still appear to be eligible to your practice," she says, but you don’t learn of that until the plan refuses to pay.

"The best way to deal with this type of situation is to deal with it before it becomes a problem," stresses Roediger. Here are some of the tips she recommends:

1. Protect your contract. Make sure your next health plan contract contains a clause stating that the HMO is responsible for absorbing — or at least sharing some part of — what it cost you to inadvertently treat an ineligible plan member.

"You should also be aware that it is possible to be contractually obligated to provide service to HMO patients for a period of time after an HMO declares bankruptcy," says Roediger. In fact, most states hold the physician responsible for patient care and might not even allow you to bill the patient in such circumstances.

Next, you want to make sure your office does everything it can to verify each patient’s insurance eligibility and receive proper referral authorizations.

2. Copy insurance cards. Every time patients — and not just new patients — visit the office, make a copy of their insurance cards. "Always update enrollee insurance information. If yours is a primary care practice, check to see that your name is on the card as the enrollee’s primary care physician," she advises.

3. Talk with patients. When patients call to make appointments or your practice calls to confirm their appointments, ask them about their insurance coverage. If there has been a change in health plan status, be sure you are aware of it in advance.

4. Review lists. Always check HMO capitation lists for enrollee names that have been added or removed. "It is important to impress upon your staff that it is vital they check the patient rosters as they receive these lists," Roediger says.

While checking capitation lists is a necessity, it is not the be-all and end-all of verification, she says. If you find useful information, such as the name of a new enrollee, use it, but remember that because many patient rosters are posted monthly or bimonthly, they are not always 100% percent reliable.

New members may not have been included, and disenrolled members’ names sometimes stay on patient rosters for months. Therefore, when a patient’s name does not appear on the patient roster, you must find some other way to verify coverage.

5. Make internal updates. Regularly checking health plan cards and capitation lists will provide you with a valuable source of information that needs to be integrated into your practice’s billing and appointment scheduling systems. In addition, it is important to establish effective ways for your front desk personnel, billing staff, appointment schedulers, data input personnel, and other office staff to communicate that information with each other.

"You can also use these data to track patients who have selected you as their provider but whose names do not appear on the rosters, which means you are probably being shortchanged on your cap payment," notes Roediger. In such cases, notify the payer of the mistake and check on any retroactive capitation payments that are due you.

6. Take advantage of technology. Technology that makes patient eligibility verification easier is emerging constantly. Here is some of the technology your payers may be using:

— Automated voice response systems directly verify eligibility over the telephone. In the typical system, the practice keys in the patient’s health plan identification number and receives the appropriate voice response. The system requires a touchtone telephone. The units also can be used to check referral authorizations or claims status.

— Swipe terminals for enrollee health plan cards provide your practice with a virtually instant response to an eligibility inquiry and work like credit card swipe terminals.

— Internet-based eligibility check systems connect providers’ personal computers with the health plan’s computers via the Internet. Internet inquiries provide real-time information about their patients’ eligibility and benefit information.