Eligibility and Deductibles: Do You Verify Before Patient’s Appointment?

Recently, I caught up with my friend Lynn Cramer. Lynn is Chief Administrative Officer at Eden Park Pediatrics in Lancaster, PA. Lynn is one of the most – if not the most – experienced practice managers I know, so I always like to glean any insight I can whenever I get the chance by asking her questions on how she has resolved in her practice issues that are a challenge to many of us.

For this post, I asked if she’d answer just a few questions that summarizes how she has structured the front desk to be accurate in the collection of important information (i.e. addresses, eligibility, telephone numbers, etc) and still remain efficient.

The question and answers are short, but there are valuable nuggets in them. Enjoy!

As far as your schedule goes, what percent is pre-scheduled and what percentage would you say you leave only for same day appointment?

We average about 75% pre scheduled visits and 25% same day scheduled visits.

The majority of your appointments are pre-scheduled, when does your staff check eligibility?

Two days prior to a scheduled appointments.

Is the front desk responsible to check the insurance information?

The billing staff (NOT front desk) verifies that the insurance information that is in our system is valid

What is the process? How does the billing staff goes about doing the checking?

The billing staff uses the eligibility check functionality in our practice Management System. If the patient is new to our office , we check [eligibility] using the payor’s website or Navinet.

Do they only check eligibility or do check other things like deductibles?

If  possible, they try to find out the dollar amount that will be owed at the time of service by the family when it shows that our services will mostly likely be paid to their deductible.

What do you mean by “paid to the deductible?”

That is an important term for your staff to learn  “paid to the deductible.”  When the family talks to your staff, they report that the insurance company told them that the service was “paid”.  The family interprets this as the insurance company paying the provider, however it is their amount to pay the practice because they have a deductible.

What happens if the patient is not eligible?

If their insurance is not valid, the staff messages (via secured electronic message on the portal ) the patient or call if needed.

Often, it is hard to reach a patient. What if they don’t respond to the secure message or your phone call?

If we get no answer, the staff will try to get a letter out in the mail so that the patient gets it the next day (day prior to their appointment). But this does not happen often. Most health insurance websites provide easy access and reliable insurance validity and deductibles.

Inevitability you’ll have a patient that is not eligible and missed all your attempts to reach them and show up for their appointment. What then?

For a prescheduled visit, if insurance is not valid and there is no proof of insurance coverage and they show up in the office we reschedule the visit or offer to allow the patient to pay up front.  There is no harm in delaying a preventive visit until payment is arranged.  The family may also want to choose a free clinic for the services.

What about same day sick visits?

We do NOT do this for sick visits.

(This blog was originally posted on Pediatric Inc)

Brandon Betancourt is a business director for a pediatric practice in Chicago. He is a speaker, consultant and blogger. You can follow him on Twitter @PediatricInc or visit his blog at PediatricInc.com.