A Proper Process

It’s a simple premise: Strengthening your intake process can reduce DSOs (days sales outstanding) and increase productivity. We began last month by discussing basic intake procedures. Now let’s move on to the insurance verification process.

For starters, make sure your company has an insurance verification form that asks the questions required to ensure that the insurance company is going to pay the claim prior to the equipment and/or supplies being delivered.

Many providers do not take the time or train their personnel to verify that the insurance company is going to pay the primary or secondary claim before the equipment is being delivered or picked up. Once the patient has the equipment in his home, it is very difficult to receive reimbursement from the patient. And just try picking up equipment after a patient has taken it home and begun using it — not an easy task.

The insurance verification form should include the following information:

• Patient’s full name and insured’s full name, as well as addresses and phone numbers. If your patient is not the insured, give the relationship to the insured.
• Employer’s information
• Policy number, group number, group name and any contract numbers
• Has a case manager been assigned? If so, speak to the case manager, because he or she will be making all decisions in regard to this patient’s care.
• Is this an HMO or PPO? Are you “in-network” or “out-of-network?” If the insurance company pays out-of-network providers, what percentage will be paid?
• Does this payer cover the equipment you are delivering? Do not just ask if HME or DME is covered. Ask about the specific equipment or supplies you are placing with the patient. Ask about quantities. Ask what documentation that particular insurance company requires. If they follow Medicare guidelines, then you will need to treat this customer as a Medicare patient.
• Is there a separate DME deductible? If so, what is it? How much has been met?
• Purchase vs. rental?
• Is monthly verification required? If so, the insurance company will require you to call them monthly to ensure coverage.
• Will payment be made directly to you? Just because you accept assignment does not mean you are going to be reimbursed. More and more insurance companies are paying the patient and expect you to be reimbursed by the patient. (You know how easy that is!)
• Is pre-authorization required? If so, you will need to get a Prior Authorization Number to place on the HCFA-1500 form when billing. Is the pre-authorization process by telephone or letter?
• Is there a maintenance option available on a purchase? Will the insurance company pay for respiratory therapist visits?
• Is there a fee schedule available?

Insurance companies are trained not to pay your claims. So, you and your employees need to be trained in how to get insurance companies to pay your claims. Put a staff member on the telephone who is very experienced in dealing with the insurance company. This person needs to be educated about the cost of the equipment and supplies, as well as in how to negotiate.

Your company’s insurance verification coordinator must know what qualifies a patient for the equipment that has been prescribed. If this employee does not understand the equipment and supplies required to be used, how can this person be effective in intake or insurance verification?

Some of the most common denials I see are:

• “Insurance terminated,” meaning the insurance cancelled on a certain date.
• There is a rider on the policy. For example, “This policy does not cover any equipment for OSA (obstructive sleep apnea).”
• “No prior authorization” obtained. This one is easy: Take the time and make the call!

I see too many insurance denials that could have been prevented if proper verification had been performed.

Jane Bunch is CEO of Kennesaw, Ga.-based JB&CS. A reimbursement specialist, Bunch delivers educational seminars worldwide, helps develop corporate compliance plans, and serves as a consultant for fraud and abuse cases. She can be reached at 678/445-1221 or via e-mail at [email protected].