Verification of Benefits

What does it mean to verify benefits and how does it differ from verifying patient insurance coverage?

If you've read the previous article on verifying patient insurance coverage, then this article might seem a little repetitive. But verifying insurance coverage and verifying benefits are really two different things.

When you verify patient insurance coverage, you are primarily concerned with whether or not the patient or the dependent is listed on the policy and whether or not they are active. This means that the patient has paid his or her premiums and that insurance will process their claims.

Just because a patient is active, however, it does not mean that insurance will actually pay the claims. In order for insurance to pay for a patient's medical claims, the patient has to be active and the service has to be a covered benefit.

When you verify benefits, on the other hand, you are checking to see if the patient has coverage for specific services, as well as how much insurance will pay for these services, if anything at all.

Different types of insurance plans

Not every insurance plan is the same.

Some include coverage for preventative services, such as routine well checks, and others include coverage for acute care services, such as sick visits and visits to the emergency department. Some plans include coverage for all types of services, but may choose to exclude certain types of services, such as elective surgeries like sterilization procedures.

This all depends on the types of insurance policy that the patient buys through their employer group plan. Usually, the more the patient pays for the plan, the better their coverage will be.

The same thing goes for the size of the group plan. An employer with a thousand employees, all paying into the same group plan, will be able to afford a better type of coverage. A smaller employer, with twenty employees, will only be able to afford a group plan that covers the basics of healthcare.

That is one of the reasons why larger corporations are able to offer better rates and policies that may include other services, such as dental and vision insurance, and why smaller employers can only offer a basic health care policy.

Another thing to keep in mind about different policies is the rates of patient responsibility. Some plans include a $20 copayment and no deductible, whereas other plans include a $4,000 deductible and no copayment.

Verification of Benefits

This also depends on the plan that the patient buys. Usually the more the patient pays for their premiums, the less they will have to pay in the form of copayments, coinsurance, or deductibles, and vice-versa.

Different types of coverage

Depending on the plan that the patient buys, their coverage will differ. "Coverage" means that the insurance company agrees to pay for the service that the doctor performs.

If the service, such as a well-child exam, is covered, then the insurance company will pay for it. If the service is not covered, then the insurance company will not pay for it, even if the patient has active coverage.

What the plan covers depends on the plan that the policyholder buys, as well as what the group plan buys.

Why is this important for the medical biller?

Verifying patient benefits is perhaps even more important than verifying patient insurance coverage. This is because the insurance might not pay for certain services, even if the patient is showing to have active coverage.

If the doctor performs a service that is considered not covered, then the insurance company won't pay for it, and instead sends it directly to patient balance. This means that the patient has to pay for the entire charge, and there really isn't anything that either the doctor or the patient can do about it.

This is especially important for the medical biller because they are the ones who have to explain the patient's coverage and bill the patient for the balance. Patient's don't usually understand non-covered services, and are unwilling to pay for them, and so they are some of the hardest balances to collect.

This means that when you verify patient coverage, you also need to verify patient benefits, in order to make sure the services that the doctor plans on performing are going to be paid.

But how do you verify benefits?

Luckily, you can verify covered benefits when you verify patient insurance coverage. Because you are already accessing the patient's information, it is the perfect time to make sure that their services will be covered.

Whether you are verifying online or over the phone, you can specify certain services to make sure they will be covered.

But how do you know which services to verify?

Usually, you verify the service that the patient is going to have performed on the day of the visit.

For example, if the patient is coming in for a sick visit, then you verify coverage for sick visits.

On the other hand, if you are working in an OB/GYN office and you are performing a service related to a woman's pregnancy, then you make sure that the woman has maternity coverage.

Some offices have a verification of benefits form, which has multiple areas to fill out, each for a specific type of service. Because commercial insurance coverage needs to be verified only about every six months or so, it saves time to fill out a form that spells out a patient's coverage. The next time the patient comes in, it is easy to simply read the page in order to make sure the service will be covered, rather than re-verify over the phone or online.

Verification of benefits and patient responsibility

One last important thing to note about verifying patient benefits is that the amount of patient responsibility may change depending on the type of service performed. For example, most insurance plans do not require a copayment for routine examinations, whereas they will require a copayment for sick visits.

Other services may incur a specified coinsurance amount, such as a 20% coinsurance for all laboratory and pathology services.

Each patient has their own specific policy, and so their coverage will vary depending on their plan. This is why verifying patient benefits, as well as verifying coverage, is so important.

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