The business functions that should be performed as part of the patient financial clearance process include:
- HIPAA business associate agreement
- Patient registration
- Communicate prior account balance
- Verify insurance coverage and benefits eligibility
- Determine co-insurance and deductible levels
- Learn prior authorization requirements
- Make demographic and insurance updates
- Learn patient’s no-show history
- Determine patient’s credit worthiness
- Deliver the patient information brochure
- Deliver the practice financial policy
The front desk staff should verify the patient’s insurance coverage with the payer prior to the visit. Staff should call the payer or, ideally, query the information on the payer’s website. If possible, real-time eligibility should be conducted. If not available, the practice can pursue batch electronic verification processes with the major payers to reduce the cost of the verification process.
Benefit eligibility verification should also be conducted for as many patients as possible, especially for those services that are often not considered a benefit by payers or for those patients who indicate an insurance change or receipt of a new insurance card from their payers.
The better informed your practice is before the visit, the more knowledge they can impart to their patients. Patients who understand their financial responsibility for the service prior to it being rendered will be prepared to pay their portion of the bill and will not be surprised when they receive a statement.
To decide on a specific strategy for verifying insurance coverage, the practice should hold a meeting with their billing department or service to review the claim denials for insurance eligibility for the past 6 months. Understanding why and what type of claims are being denied by payers helps the practice effectively allocate resources to patient financial clearance.
If the denial data indicates that a high percentage of claims are denied due to the patient not being eligible or due to incorrect payer, the practice should consider dedicating staff and IT functionality and oversight to the insurance verification function.
To avoid common problems associated with coordination of benefits, the practice should ask patients for both primary and secondary insurance while they are scheduling the appointment.
A financial policy provides the details of the practices’ expectations in writing. Once the policy is written, it should be shared with patients, providers and staff. The policy should be reviewed each year to determine if updates are warranted. The policy should include not only specific financial protocols and expectations but also information on how to handle deviations from the policy. Reminders of the key elements of this policy should occur at appointment reminder calls and check-in and, a summarized version should be posted in the waiting room.