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How in the Heck do I Verify a Patient's Insurance?

Let me start by saying that insurances are one of the most confusing things you will ever encounter in your practice. You have gone through hours and hours of graduate school, have obtained your Masters and possibly even Doctorate degrees, but insurances will leave you feeling like the most incompetent person on the planet. Every insurance plan is different. Every state is different. Every payer is different. Some payers want a certain modifier and some don't. They will deny claims for the most insane reasons. You age about 5 years every time you call and get placed on hold for 45 minutes in order to be transferred at least three times before you MIGHT get an answer. It is enough to make you pull your hair out, and then you realize why providers are cash pay only. I wanted to give you all a little script to make your life easier when calling to verify insurances for your patients. Yes, I said call - because you can not depend 100% on your EHR to correctly run eligibility, nor can you depend on other sites to give you the correct information. You MIGHT not even get the correct information when you actually call the insurance company directly. But at least you will have a name and a reference number to refer back to when you do. Make sure you document all of this information in your patients record somewhere - so that you have it to refer back to in case a claim gets rejected or something weird happens after submission of the claim.

Script for Verifying Insurance

  1. When you reach the prompts - you will choose whatever automated number option you are given for claims and eligibility - or maybe even member eligibility. Hopefully, you will get to speak to a human.

  2. “Hello - I am calling to check the eligibility and benefits for a new patient for Outpatient Mental Health Provider services at a providers office."

  3. “I also need to verify that I am listed as an in-network provider for your panel, can you please check?” (They will ask for your NPI and Tax ID)

  4. If they verify that you are in-network - “Great, and I want to verify you have the correct address for my office, it’s <give full address>”

  5. They will ask member information - so have it ready. “The subscriber ID, date of birth, and first and last name are..”

  6. You want to make sure that the patient does have mental health benefits (there are policies that do not) “I want to confirm this patient does have mental health benefits and that there are no limitations on their mental health benefits, and that there are no prior-authorizations required for this patient” (Some insurances will restrict certain diagnoses - personality disorders, transgender issues, and even mood disorders!)

  7. “I wanted to confirm the following CPT codes will be covered under the policy plan: 90792, 99213, 99214, 99215, and 90833” (these are the most common - but you may have others)

  8. “What’s the copayment or coinsurance for this patient?” (Write it down - this is what you are going to collect from the patient at or BEFORE the visit). Never bill these out after the fact - sometimes you will have difficulty collecting. These fees can NOT be waived and it is usually a condition of your contract agreement with your payer.

  9. Does this patient have an outstanding deductible?” (If the patient has not met their deductible - you charge them the full amount of your insurers contracted amount for the code they will be charged for - at or BEFORE their visit!)

  10. “What address should I send my claims to?” (This is VERY important - as is the payer ID - your claim will be denied if you send it to the wrong place.) Some insurance have multiple addresses.

  11. “What is the Payer ID for electronic claims?” (Some insurances will have multiple payor ID's)

  12. “Thank you so much for your help, can you please provide me your name and a reference ID for this call for my records?”

If you ask these questions every time you check insurance and eligibility - you will save yourself a lot of headaches later down the road.

If you are in need of help with billing - Silver Leaf Practice Management Solutions, LLC can HELP! Contact us TODAY!


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