Main Point

• • • Look out for deductible information

    • Look out for copay information

    • Look out for out of pocket information

---

 

As you are creating your verification of benefits process (VOB) you will want to be on the look out for a variety of different information. One of the best ways to help eliminate the complexity of information is to create a standardized form that includes the information in this blog. At the end, we will give you an example form that you can use in your practice.

Since verification of benefits can include a wealth of information, you will want to be on the look out for very specific information and you will want to document that information in a unified format.

Before you get started there are a few items that you will want to prepare. Make sure that you follow this checklist before beginning your eligibility and benefit check:

1. 1. 1. A copy of the patient’s insurance card, both the front of the card and the back of the card

      2. The number to call from the back of the insurance card. If it specifies which benefit (i.e. mental health) you will want to contact that number.

      3. The patient’s first name, last name, and date of birth. This information will need to match exactly what is on the patient’s insurance card

      4. A form template for capturing the insurance information that you are going to collect

      5. Leave room in your schedule to be on the phone for about 40 minutes per eligibility and benefits call

---

 

Look out for deductible information, copay information, and out of pocket information. Let’s say you are on the phone with an insurance representative and you are trying to figure out what the patient owes and what the insurance owes. You will want to find the following information:

Deductible Information

A deductible is the amount that a patient owes for care before the insurance company will pay for services. Therefore, when a patient has a deductible, they will be responsible for the entire amount of the session before the insurance company will pay anything.

For example, if a patient has a $3,000.00 deductible and your allowable amount is $100.00, the patient will have 30 sessions paying $100.00 before the insurance company pays anything.

Copay or Coinsurance Information

A copay or coinsurance is the amount that a patient owes after the deductible is met. Therefore, if a patient has a $20.00 copay after their deductible, the patient will pay $20.00 per session after they have met their deductible.

Or if a patient has a coinsurance, they will owe a percentage of the allowable amount. For example, a patient have have an 80/20 plan where the insurance plan will pay 80% of the allowable and the patient will owe 20%.

Therefore, if your allowable amount is $100.00 then the patient is going to pay $20.00 and the insurance will pay $80.00.

What if your allowable is a strange number? That is a good question!

If your allowable is a funny number like $101.32 and the patient owes a 20% coinsurance you would multiply $101.32 by .20 to get the patient amount. So….

                                                       $101.32 X .20 = $20.26

                                            So you would charge your patient $20.26

Out-of-Pocket Maximum Information

An out-of-pocket maximum amount is the TOTAL amount that the patient should pay for medical services in a given year. Once the patient reaches this amount, they should owe exactly $0.00 for your services for the rest of the plan year.

This is number is usually very high. It is not uncommon for an out-of-pocket maximum to reach or exceed $5,000.00 or $10,000.00. However, all medical expenses count toward the out of pocket maximum.

Therefore, it is not uncommon to have patients start treatment in August, September, or October that owe $0.00 out of pocket for your services.

NOTE OF CAUTION: Be sure to monitor how those claims process, because if the insurance company doesn’t pay, that could lead to free services

---

 

VOBs and getting information that you need in order to properly bill can be difficult, but creating a clear system and process of getting that information is integral to your mission of providing excellent services to patients.

Here is an example of an eligibility check form that you can use for your practice:

Updated as of: TODAY’S DATE

Deductible: Amount of the deductible met:

Copay:

Coinsurance

Out of Pocket Maximum:

Amount of the OOP met:

Number called:

Representative:

Reference Number:

Authorization needed for code 11111: Yes or No:

If you are finding that you are having a hard time keeping up with verification of benefits, or that you are struggling to obtain the necessary information, Practice Solutions can help. Our billers perform eligibility checks as part of our insurance billing service, in addition to submitting and following up on claims, posting payments, and assisting with denials and rejections. Contact us today to learn how you can spend more time with your patients and less time worrying about billing!