Eligibility checking is one of the foundations of proper billing. This is the process by which the practice verifies the insurance status of the patient before services are rendered; the second aspect of eligibility checks is careful examination of the information received and matching it against the practice’s billing records. Time and again, we’ve seen eligibility verification results that specifically say the patient is inactive, were unprocessed due to an error or verify eligibility for a different line of business. Sadly, front desk staff is sometimes rushed or multi-tasking and may not catch these issues, or may see what they expect to see. In other instances, staff have been poorly trained on what to look for in a verification result or the practice may outsource the eligibility function to people who don’t read the information correctly.
Eligibility checks should be done at every visit and ahead of time. Some practices rely on the membership roster from the managed care plan to ‘verify’ eligibility rather than performing a specific check just prior to the visit. In other instances, we’ve encountered offices who check insurance status for the first visit of the month, without considering that plans can retroactively disenroll a member, or that the member may default on the premium payment later in the month and be ineligible for services.
We recently found a few examples where members of a PPO plan were entered into the billing system as having a capitated HMO plan. Instead of billing fee-for-service claims, the practice submitted encounters, which have no payment. [Mind you, the eligibility checks and ID cards clearly reflected the members had PPO insurance.] By the time the practice realized the error, intending to correct and resubmit the claims, the filing deadline and dollars were long gone.
Make sure your practice has a precise eligibility verification process for each and every visit, and that billers spot-check results to ensure accuracy. Given the ability to submit electronic verifications, even in batch form, there’s no excuse for not performing the critical function.
Read the next installment in our Billing No-Nos series: Diagnostic testing global fees.