Good Insurance Verification Gets You Big Bucks

By Deb Tru

Calling All Practitioners

Step one in Maximizing your Profits

Successful insurance billing starts with successful insurance verification

The Biller needs to be very specific when we verify insurance coverage so we do not bill out for procedures that will never be reimbursed.

I have had some providers who do not want to pay the extra fee that is required to proved insurance verification, and these providers have lost much more money in neglecting to verify insurance than they would have paid me to perform the service. Penny wise and pound foolish?

So whether you, as a provider, do your own verification or if you rely on your front desk or billing service to do your verification, be sure it is being done correctly!

Is the Playing Field Even?

Perhaps you have noticed that when you call the insurance company, the first thing you will hear is the gratuitous disclaimer. The disclaimer states that no matter what takes place during your telephone conversation, chances are if you were given incorrect information, you are out of luck. The disclaimer may include the following statement: "The insurance benefits quoted are based upon specific questions that you ask, and are not a guarantee of benefits." If you do not ask for details, they may not tell, so you are starting out with the short end of the stick! And since you are already at a disadvantage, then get a firm grasp on that stick and cover all of your bases.

To start with, you will need much more information than the online or telephone automatic system will tell you. Try to bypass the auto systems as much as possible. Ask the automated system for a 'representative" or "customer service" until you actually find yourself talking to a real person.

Key Points for full reimbursement

I will provide an insurance verification form that you can use. Here are the key points:

The representative will give you their name. Write it down along with the date of your call. If you are out of network with the insurance company, get the in and out benefits, just so you can compare the difference.

Deductible Information Essential

Find out the deductible, then ask how much has been applied. Then ask, specifically, if the deductible amounts are common. If you do not ask, they will not tell you! If deductibles are common, you can be fairly certain that the applied amounts are correct. If the deductibles are not common, find out how much has been applied to the in network plan and how much has been applied to the out of network plan.

What does Common mean? Common deductible means that all monies applied to deductible are shared. Any funds applied through an in network provider will be credited for the in and out of network providers.

Second question: Is there a 4th quarter carry over? This is good to know towards the end of the year. If your patient has a one thousand dollar deductible and it is October, any money applied to that one thousand will carry over to next year's deductible. This can save you and your patient some big bucks. If you do not ask, they may not share this information with you.

Know Your Limits

Since we are discussing Chiropractic, you will ask about the Chiropractic maximum. What is the limit? It may be a number of visits, it may be a dollar amount. If it is a dollar amount, then ask: Is this limit based on what you allow, or what you pay? Some plans consider the allowed amount the determining factor, and some will consider the paid amount as the determining factor. There is a big difference between the two!

If you bill Physical Therapy-and if you don't, then you should!-ask about the Physical Therapy benefits. Can a Chiropractor perform Physical Therapy? If the answer is yes, then ask: Are the Chiropractic and Physical Therapy benefits combined, or are they separate? Usually you will find something like: 12 Chiropractic visits and 75 Physical Therapy visits are allowed. If they are separate, then after your 12 Chiropractic visits, you can begin to bill Physical Therapy only. If you add a Chiropractic adjustment on the claim after the 12 visits, that claim may be considered under the Chiropractic benefits and you will not receive payment. If you bill Physical Therapy codes only, then the claim will be considered under the Physical Therapy benefits and you will receive payment.

We're Not Done Yet!

However! You need to be even more specific about this. After being told that the Chiropractic and Physical Therapy benefits are indeed separate, and you have been told that a Chiropractor can bill Physical Therapy, then ask: Is Physical Therapy billed by a DC considered under the Chiropractic or the Physical Therapy benefits?

At this point you can almost see your insurance representative roll their eyes at your incessant questioning. Don't worry about that, just get the information. Sometimes you have to ask the same question a few different ways to get a complete reply.

I have gotten caught from not asking this question. Some plans will allow a Chiropractic to bill Physical Therapy, but if the doctor is a Chiropractor, then anything the doctor bills will be considered "Chiropractic Benefits." In that case, you will only be reimbursed for the maximum number of visits allowed to a Chiropractor, even if you can bill Physical Therapy also.

There are plans that will allow a Chiropractor to bill Physical Therapy codes after all of the Chiropractic benefits have been exhausted. How will you know if you do not ask?