Professional Documents
Culture Documents
1 Fri 1045am Lowenwirth
1 Fri 1045am Lowenwirth
1 Fri 1045am Lowenwirth
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The objectives of this presentation
3
Verification Defined
4
The Importance of Verification
Insurance is inforce
If it is medically necessary
5
The Importance of Verification
6
Gatekeepers
7
“ But I have insurance !” ….
What do we Verify?
Eligibility
Coverage/Benefits
Policy Limitations
Financial Responsibility
8
“ have you met your deductible” ….
What do we verify?
Eligibility:
If the coverage is in force (effective date)
Premiums are paid
Coverage:
Is it a covered service (i.e. well exams, sick visits, maternity, etc. )
Who is the Subscriber (Patient, Spouse)
Primary vs. Secondary
In Network vs Out of Network
9
… they paid the last time I was here” ..
Policy Limitations:
Preventative services
Contracted services
Are pre-authorizations or pre-certifications required
Pre-existing
10
Why are claims Denied
11
Life Cycle of an Endoscopy Procedure
4. Procedure
3. Physician
is 9. Post- call /follow
recommends
scheduled/Instructions up
procedure
12
Billing Process
Make an Pre-certification
Verify Pre-
certification
appointment
Review with
patient /Discuss
Eligibility Coverage financial
responsibility
Pre-registration Verification
DOS
Rerun!
Verification Process
Call patient to
1. Patient makes Verify
review financial
appointment authorization
responsibility
Verify eligibility
and 5. Obtain DOS
authorization Collect co-pay
Benefits
call patient
3. Needs referral
/referring 9. Submit Claim
/pre-certification
physicians
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Fee Transparency
Co-pays/co-insurance
For Providers
For Patients
Demographic
• Name, Address, Telephone, e-mail, SS#, DOB, DOS, Emergency Contact, Employer
Insurance
• Policy #, Group #, Subscriber #, PCP, Referral, Pre-authorization – aka- pre-cert, Verification,
Eligibility, Benefits, Primary, Secondary, Active Coverage, Benefits, Deductible, Co-pay, Co-
insurance, Out of Pocket, Stop Loss, Insured, Relationship to Insured, Guarantor, Claim, CPT,
ICD-9 (now ICD-10) Bills, Statement, EOB, Collection.
Clinical
• Symptoms, consult notes, H&P, Indications, NPO, BMI, Medications, Allergies, Advance
Directive, Glucose, BP, prior surgeries, do you smoke ?, do you drink ? Implants ? Dentures,
The anatomy of a visit
Social Physician
RNs/ NPs/
Insurance
PAs/Techs
• Pre- assessment •A
• Consenting • Insurance Eligibility and
• Pre-Op Care Verification of benefits
• Post- Op Care • Advising patient of financial
• Discharge responsibility,
• Follow up call
• Collecting $$$$$
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Bundling
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Bundling
More conducive to some procedures where an “episode of care” can be clearly defined
from beginning to end.
Colonoscopy
Joint Replacements
Cardiovascular
OBG
Key Factors
Must know your cost
Assume Risk
Shared Savings
Relationship of Multiple parties
Conclusions
The current environment is very complex with many factors working against
healthcare providers to collect payments