Checkpoint: Eligibility, Payment, and Billing Procedure

Checkpoint: Eligibility, Payment, and Billing Procedures * * Describe at least one factor that determines patient benefits eligibility (p. 86-87).
If a patient has an HMO that may require a primary care provider, the general or family practice must verify a few things first. First the provider has to be a plan participant, second the patient must be listed on the plan’s master list, and third the patient must be assigned to the PCP on the date of service. The medical insurance specialist will then make sure that the patient is currently covered by their insurance. If web information is required the specialist and the provider’s representative will exchange information online. If the payer wants to use the telephone the representative will be called. The patient’s benefits will also be checked for what that insurance covers for them. There are some plans that do not cover all benefits, for example, maternity coverage and diagnostic x-rays, may not always be cover by a person’s insurance plan. * * What are the appropriate steps to take when insurance does not cover a planned service? (p. 87-88)
When a patient’s insurance does not cover the services that they are trying to receive, the patient is told they will be held responsible for the entire charge. The patient must sign a financial agreement plan before the provider will move on with the visit. Once the patient does sign this agreement, the patient will be seen and will be charged for any services from that visit. * * Why do you think it is so important to make sure patients understand their payment obligations before they receive services? * It is very important that a patient understands that their coverage does not pay for the service that they are trying to receive. If the provider just went ahead and seen the patient knowing that their insurance did not cover them and then proceed to charge the patient the full amount on the bill, I think they could get into trouble. The patient may be able to sue the practice for failure to explain before the visit. If you do not tell the patient and have them sign a form, then you should not get your money. * * What are some possible consequences to the patient or provider if financial obligations aren’t properly disclosed before services are given? * I believe that a patient may be able to sue the practice for failure to explain before the visit. If you do not tell the patient and have them sign a form, then you should not get your money. The patient is not responsible for the provider or staff’s mistake. I think that a patient should know what their insurance covers before they proceed to go and see their provider, but it is still the provider’s responsibility to ensure that they cover all the necessary steps to get paid their money. *

Reference:
The McGraw-Hill Companies, 2008. Patient Encounters and Billing Information. Medical Insurance ch.3, p. 86-88. Retrieved July 27, 2010 from University of Phoenix