Importance of Verifying the Details of Insurance Policies
By: Nicole Zurawski, Reimbursement Supervisor, MRS
In a home infusion business, the intake coordinator is the first step to ensuring that your billing goes smoothly. If errors occur in the beginning, they are likely to continue throughout the billing process, eventually resulting in denied claims. Even worse, if the proper procedures are not followed from the start, denied claims could become completely uncollectible. This will mean no payment for the high-quality services you provide.
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See our guidance below for details that intake coordinators should verify when working with payers. Taking these steps will help your billing staff send correct claims the first time (either on paper or preferably electronically) for fast reimbursement.
1.Verify patient insurance from A to Z: The intake coordinator needs to check with the insurer’s benefits department to determine many factors before accepting the patient on service. Below are a few important areas to consider:
**Type of policy: Determine if this a commercial, Medicare replacement, or even Medicaid-managed care policy because these three types of policies could be very different, even under the same payer. Commercial policies usually require billing with per diems using S-codes while Medicare and Medicaid policies require billing in kits. However, the billing methodology could differ from state to state and even payer to payer.
**General eligibility: If you are a contracted provider, you may be able to verify eligibility online. However, if you are accepting a patient on service for a payer that you are not contracted with or a payer that has a history of giving incorrect information, it is STRONGLY encouraged that you get the name of the person you are speaking with and always ask for a reference number for the call. This way, if there is an issue later, you will be able to prove that you followed the instructions you were given.
**Out-of-pocket responsibility: These days, deductibles and out-of-pocket limits are enormous. Therefore, you need to determine the total out-of-pocket amounts for which each patient is responsible and discuss this before initiating the service. Often, patients or their families will agree to pay any amount to get a patient home. However, if you wait until patients are home to address their financial obligations, they are already home and the incentive to pay is no longer there. The margins are so slim in today’s infusion world that you can’t take this risk anymore. In fact, most providers are now requiring payment up front before delivery is made and, in some instances, payment in full before payers have even made their final determinations.
2.Determine if prior authorization is needed: Once you determine the type of policy, you will need to note if prior authorization is required. Below are a few tips on authorizations.
**Not all plans require authorization: Medicare replacement plans do not typically require prior authorization since traditional Medicare does not; conversely, commercial and Medicaid plans routinely require an authorization.
**Some limitations may apply: If you are granted an authorization, you need to be very clear as to what is covered under this authorization, including drugs, supplies, and nursing visits. Are there maximum quantities that can be billed, and, if so, did you authorize the correct units? Did you authorize all of the services being rendered? The devil is in the details, and all too often when billing, we are faced with the need to fight for payment because something was missing or insufficient when an authorization was requested. Always document your interpretation of what is covered under the authorization and to whom you spoke. Note: Authorizations are NOT guarantees of payment. You should always confirm eligibility before obtaining authorizations.
**Beware of “authorization not required”: While there are payers that do not require authorization for home infusion therapy, that is the exception rather than the rule. If you attempt to get authorizations and are told they are not required, determine why it is not required. Does this apply to just your pharmacy or to all pharmacies? You should also ALWAYS request a reference number for the conversation along with the name of the person with whom you spoke. If your claims are denied later, having a reference number along with the time and date of the call and a person’s name will help you to either resolve denied claims or get retro authorizations.
It is crucial that your intake team and your billing team stay in sync so that the proper information is collected initially, and clean claims are billed the first time. Proper training of staff and attention to the details above can prevent hours of re-working claims and managing denials.
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