Insurance Verification is Key for Processing Clean Claims

Posted by Sherri Dement on Wed, Dec 02, 2020 @ 08:12 AM

During times of uncertainty, many practices may be struggling financially. Challenging times make it essential to ensure that you are appropriately reimbursed for all services rendered. Verification of benefits is necessary to understand the patient's medical benefits and what procedures are covered under the plan they have chosen. Accurate verification of benefits is vital to the financial success of your practice.

Now is an opportune time to examine the verification process with your staff and confirm that the appropriate employees have a solid understanding so that you can start 2021 off on the right foot.

Unfortunately, it is not uncommon to come across practices without policies in place for verification of benefits. It is impossible to know what services will be covered without verifying. Is this your practice? Are you treating patients and providing your time and expertise and not being reimbursed because benefits were not obtained or are not clear?

The Importance of Eyecare Insurance Verification in 2021

verifyThe process begins when the patient calls to schedule their appointment. Often, vision plan details are easily obtained; however, for some reason, it seems that there is a hesitation when asking for medical insurance details. It is beneficial to train your staff on the questions they should be asking patients to get the needed information. You may want to provide a template of questions to get asked and answered when the patient calls to schedule. Let your patient know upfront the visit could be routine or medical, depending upon their condition. Having access to both the vision and medical verification at your fingertips provides you an opportunity to transition from a vision exam to a medical when the need arises with a little more ease. It may be that you complete the vision and bring back for the medical or vice-versa.
However, without having access to both, you will not be aware of your options. Verifying the patient's benefits before their appointment allows time to contact the patient if there are problems with their insurance. Many patients will bring a vision card to their exam but do not even think to bring their medical insurance card, so having the conversation when the appointment is scheduled can alleviate this problem.

There are a variety of ways to obtain verification of benefits these days. The more detailed the questions the more valuable the information. Your office can utilize your clearinghouse for eligibility verifications, Availity, specific carrier websites, or IVES (Insurance Verification and Eligibility System), which is an optometry specific verification system that is proprietary to OMS. The IVES system that OMS offers allows your staff to focus on collecting the proper data, while utilizing our resources to obtain detailed verification information for your patients. Here are the steps you follow:


  • Is your patient the subscriber or a dependent?
    • If they are a dependent do you have all information necessary on the subscriber (Primary member).
    • Are dependents covered?
  • Has the patient provided the most current card from the Payer?
    • Do you have the correct card for Medical? Vision?
    • Confirm the card is not for Dental or Prescriptions.
    • Do you have the correct ID and Group number for the plan?
    • An insurance card does not mean the subscriber ID is accurate.
    • Due to privacy, Carriers have changed patient IDs and issued new cards. If you are not verifying, you do not know if you have the most current information.
  • What is the Payer ID?
    • Rejections can occur if the claim is not submitted appropriately.
  • What is the effective date of the plan?
    • Just because the patient provides the information to you does not mean their coverage is active.
  • How much is the annual deductible?
    • Do your staff understand the term?
    • Is there a Family deductible? An Individual deductible?
    • How much of the deductible has been met?
    • Is there an out-of-pocket expense?
Now that the verification has been obtained, you need a plan to deliver the information to your patient. Often the staff will say the patient is not prepared to pay their deductible. Let it be known that the patient is aware of their deductible when they choose their plan benefits. If their employer provides coverage, they are given documentation that clearly outlines their benefits and may also have a member website for additional information. You should never be apologetic when asking the patient to pay their copays and deductibles as they are aware of their responsibility. More importantly, the contract you have signed with the carrier states that it is your responsibility to collect copays and deductibles. By not collecting copays or deductibles, you can risk being dropped as a participating provider. If the patient refuses, you can inform them that this visit can be a "self-pay" if preferred.
Work at this now to prepare for 2021! Beginning in January, most of your patients will have to meet their deductible. What is your policy for collecting deductibles, copays, or a percentage of what is due? Do not be apologetic to the patient for their plan and their choices. Educate and collect.

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Tags: Coding & Billing

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