Thursday, 19 January 2017

Medical Office Workflow Step 2: Proper Insurance Verification

For successful claims processing and payment, it all starts with the proper verification of insurance coverage and benefits.

Proper claims reimbursement

Follow the guide below to ensure you are gathering all the necessary information to create a complete and accurate patient benefit profile.

Medical billing hint 

Basic information needed before contacting the insurance company:

1.First and last name of patient and the subscriber (if other than the patient)

2. Patient’s date of birth

3. Policy number as shown on the insurance card

Medical billing hint

(The insurance card is one piece of essential information your patient should bring on their first visit.  Please see this New Patient Checklist other important documents, etc.)

4.Diagnosis or chief complaint

5. CPT codes for anticipated procedures

Verify medical benefits

Ask these questions to build your patient benefit profile:

1.What are the effective dates of the current policy?

2.Are they any pre-existing conditions limitations?

3.What are the benefits for the anticipated service?

a.Does a deductible apply (see b) or only a copayment (see d)?

b.If there is a deductible, how much is the deductible and how much is met?

c.After the deductible, what is the co-insurance amount?

d.How much is the copayment?

e.What is the annual out of pocket maximum and how much is met?

f.Do the deductible and copayments apply toward meeting the out of pocket maximum?

4.Does this policy require any type of authorization of the anticipated service(s)?    If yes, make sure to obtain the proper contact information for that internal department or outside agency.

Verify medical benefits : If you are unaware of the entities process for obtaining authorizations, immediately contact them by phone or review available information on their website.  This is a huge time saver to have this information on hand before you may actually need it.

5.Is there an annual, lifetime or per illness/diagnosis maximum benefit?  If so, how much has been met?

Medical billing terms : If some of the above terms seem confusing, refer to the table below for helpful explanations.

Pre-existing Condition

Most often occurs with a lapse of insurance coverage.  The new insurer can refuse to cover a condition that was diagnosed before the effective date of the policy.


Amount the subscriber is responsible to pay before insurance will pay their portion.


A flat rate assigned to specific procedures that the subscriber is required to pay.  Most commonly to office visits and outpatient diagnostic procedures.


The percentage of the charge that is the subscriber’s responsibility.  Refers to benefits like”80/20”, the insurance pays 80%, the patient pays 20%.

Out of pocket Maximum

This is the total patient’s out of pocket financial responsibility designated by the payer.  Once the subscriber has met this amount, services then become covered at 100% by the payer.
Benefit Maximum

This is the monetary payment limit set on the subscriber’s policy.  Once this maximum is reached the payer has no more financial liability and the subscriber must pay for the rendered services.

Iridium Suite

Practice Management software from Medical Business Systems has an integrated insurance Real Time Eligibility function that can do most of this work for you.  See how Iridium Suite can help you “work smarter not harder”.

Office Workflow Step 1: New Patient Check List

When scheduling a patient for their first visit to your practice, you should advise them of what they need to bring to help ensure a smooth registration process and to assist your physician in making that first visit as thorough as possible. 

Follow this check list as a guide:

Picture identification and current insurance card(s)

Hint:  Once provided with this information, you need to verify insurance coverage and benefits.  This is the optimum time to collect copayments from the patient.

Contact information for emergency contact and/or healthcare surrogate

Hint:  Make sure the patient indicates the name(s) of any authorized persons on your HIPAA notification form.

Contact information for all current healthcare providers

Hint:  Please have the patient add to the HIPAA form, the names of any physicians they would like your physician to communicate with or share their medical records.

Copies of any applicable medical records and recent diagnostic testing results

Hint:  If you are handed records that are the patient’s only copy, make your own copy and return the “originals” to the patient.  They may need them for another provider.  X-rays or radiology “films” stored on computer discs, should be logged in the patient’s record if they are left behind after the visit.

Complete list of current medications, both prescription and over the counter.

Hint:  Adding the pharmacy name and phone/fax number into the patient chart facilitates issuing any required prescriptions.

Observe National Women's Health Week

National Women’s Health Week is May 12-18 and is a weeklong health observance coordinated by the HHS Office on Women's Health.

Per 2009 statistics from Center for Disease Control and Prevention Office of Women’s Health the top three causes of death in the United States for women are: heart disease, cancer and stroke.

Take this week to encourage all the women in your life to make their health a priority. Have them schedule preventative medical services and screenings such as:

Annual physical including basic lab tests Cancer screenings (mammogram, pap test, pelvic exam, clinical breast exam, and colorectal cancer screening)

Information on women's health

CMS now covers many preventive services and screenings under its Medicare Part b benefits for eligible beneficiaries.  For further information see the following:
  • MLN Preventive Services Educational Products for Health Professionals
  • CMS Prevention website
  • CMS Immunizations website
  • Discuss the importance of making healthy lifestyle choices:
  • Participate in regular physical activity for a minimum of 2 and ½ hours per week.
  • Consume a healthy daily diet of fruits, vegetables and whole grains, with limits on foods with high calories, sugar, salt and fat. 
  • Eliminate tobacco use and avoid tobacco smoke exposure.
  • Limit alcohol consumption to one drink per day.

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