Insurance Eligibility Benefits

Most medical insurance plans are complex. Some private practitioners accept insurance but many don’t. Why wouldn’t someone accept insurance and do the billing for you first?

It doesn’t matter which plan or company it is, dealing with insurance companies and plans takes time. And then there is also no guarantee that the practitioner will be paid by the insurance company. If the benefits are mentioned initially on the computer or telephone, there still is no guarantee that there will be payment made for the services provided.*. Insurance Eligibility and benefits

If the insurance company does not pay, then the practitioner has to spend even more time getting the patient to pay what is owed for services rendered.

But in the beginning, the possibility that a patient’s insurance might cover the treatment for a particular diagnosis is based on whether there is eligibility. In other words, does the patient have a contract with the insurance company they say they do, and when did they become eligible for that coverage?

If the patient is eligible for some coverage due to their contract, the next question is whether the particular service is a benefit. Not all plans cover acupuncture, and even fewer cover functional medicine.

Next, if there is a benefit, does that benefit cover or apply to treatment of a particular diagnosis?

And is that treatment medically necessary?

Now you are beginning to see how complicated the process is.

How many times does a practice have to check on these things? Some plans authorize a number of treatments over a particular time period. Others do it one by one.

But just with respect to checking on one factor, eligibility, what does a major insurance company say themselves regarding how often the provider needs to check with them?

“Patient eligibility and benefits should be verified prior to every scheduled appointment. Eligibility and benefit quotes include membership verification, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. It’s strongly recommended that providers ask to see the member’s ID card for current information and photo ID in order to guard against medical identity theft. When services may not be covered, members should be notified that they may be billed directly.”

That takes up a lot of time the provider could better spend learning what else you need during a treatment visit. Any wonder that doctors have so little time to get to know you if the insurance plan calls take up so much staff and doctor time that is not reimburseable?

* Typical Insurance Company Caveat: “Please be advised that a quote of eligibility and benefits is not a guarantee of payment. All benefit payments are subject to eligibility, medical necessity, and the terms, conditions, limitations, exclusions, and payment leels of the patient’s health benefit plan at the time the services are rendered. Benefit payments are usually not determined based on billed charges and might be significantly less than billed charges. Please not newborn dependents not listed on the membership file may have benefits available. All claims should be filed to the state in which the service was rendered unless otherwise specified under the members contract.”