Chiropractic Assistants Insurance Verification Training Guide

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1 Chiropractic Assistants Insurance Verification Training Guide What You Will Learn: How to Obtain Maximum Chiropractic Benefits Tools Needed to Verify Benefits Understanding Why You Are Verifying Understanding How Insurance Verification Affects the Practice s Revenue Understanding the Different Types of Insurance Plans Understanding the Verification Verbiage Secondary Benefits W/C Worker s Compensation MVA Motor Vehicle Accidents and PIP Personal Injury Protection

2 How to Obtain Maximum Chiropractic Benefits To accurately verify a patient s insurance benefits it is important to know and become familiar with the types of services, procedures, and treatments that are most commonly performed in the chiropractic practice, e.g., exams, x-rays, chiropractic manipulative therapy, and physical medicine/rehabilitation procedures. It is also important to become familiar the CPT codes (Current Procedure Terminology) associated with the services that are used in the practice. Look at the fee schedule/super bills/ or previous claims filed and learn what CPT codes are assigned to the specific procedures/services. Become of aware of the ICD-9 (International Classification of Diseases) a.k.a. Diagnosis Codes or DX (acronym) that is used. Look at the diagnosis coding sheets to see what codes are assigned for specific illnesses or injuries. The Place of Service is also important in determining benefits as a carrier will frequently want to know if you are seeking to obtain benefits for in-patient or out-patient procedures. For the chiropractic practice the most common place is: Office/Out-Patient. For a detailed list of Place of Service codes reference the below link: Always follow the New Patient Data Collection Form and Instructions when making the new patient appointment. It is important to gather as much information as you can in order to pre-verify insurance benefits prior to the patient s first appointment. There are 2 ways to obtain insurance benefits: 1) Call the 800 Provider or Customer Service number located on the patient s insurance card; 2) Enroll in the insurance carrier s provider system on the internet. Obtain a log-in user name and password to check benefits. (Note: Most online verifications are very general in nature and do not allow you to ask specific questions about coverage issues). If any of the information you have obtained from the patient is incorrect, call them back right away to obtain the correct information. If a PCP referral is required make sure you have called the PCPs office and obtained by fax the written referral prior to the new patient s appointment.

3 Tools Needed to Verify Benefits Insurance carriers telephone number or website The CPT Codes Insurance Verification Form Information obtained from the patient when the appointment was scheduled.

4 Understanding Why You Are Verifying Why Do We Verify Insurance Benefits? Verify benefits to maximize provider and/or patient reimbursement Verify benefits to determine patient responsibility at the time of service Verify benefits to determine what services are or are not covered Verify benefits to make sure the provider is paid Verify benefits to obtain maximum benefits available Verify benefits because it s your job and responsibility to the doctor and practice to do your very best!

5 How Insurance Verification Affects the Practice s Revenue Verification of insurance benefits is not a guarantee of payment. Many carriers will give you a disclaimer when you call them stating that the benefits they are verifying is not a guarantee of payment. Payment is determined only when the claim has been received and processed. It is important to understand how to ask the verification questions in order to obtain the correct information from the carrier s representative. The very reason the patient is being seen could cause the claim to deny. Know the chiropractic practice s services, procedures, and products to obtain the maximum and correct benefits from the carrier. Taking short-cuts during the verification process results in a short-cut of revenue. Realize that the insurance representative is reading to you what they see on a computer screen. They do not know you or the patient, nor do they know why you are calling them or what you need. They can t read your mind. Be very specific when you ask benefit questions. Press for the information you need or give them a scenario to make sure they understand what you are asking for specifically. Know that the money that is NOT collected AT THE TIME OF SERVICE is valued less due to the costs associated with overhead and billing at a later date. That is why it is so important to determine patient responsibility prior to the first visit. Know that YOU are the most important and strongest link to maximizing the practice s revenue!

6 The Different Types of Insurance Plans HMO: A Health Maintenance Organization that provides health insurance coverage to its members through a network of participating providers, hospitals, and other healthcare providers. (May require a referral). POS: A Point of Service carrier that provides health insurance coverage and allows its members to go out of its network of providers and hospitals, but requires its members to pay higher out-of-pocket costs. (Referrals and prior authorizations may apply). PPO: A Preferred Provider Organization that provides health insurance coverage using a group of providers, hospitals, and other healthcare providers who contract with the carrier to provide services to its members at a discounted/contracted rate. The PPO also provides health insurance coverage for services that are rendered by out-of-network providers at a higher out-of-pocket cost to the member. (No referrals necessary). EPO: An Exclusive Provider Organization that provides health insurance coverage using a group of providers, hospitals, and other healthcare providers but does not cover any out-of-network services. (No referrals necessary). MSP: Medicare Secondary Payor is when Medicare is the secondary payor because the beneficiary has coverage through a group health plan, worker's compensation, or there is other third party liability. Medicare Advantage Plan: Is another Medicare health plan choice offered by private companies approved by Medicare. The Medicare Advantage Plan will provide Part A and Part B coverage, and may offer additional coverage such as vision, hearing, dental, and prescription drug coverage. PFFS: A Private Fee-For-Service plan is a Medicare Advantage (MA) health plan that provides beneficiaries with all their Medicare benefits plus any additional benefits the company decides to provide. Beneficiaries can see any provider who is eligible to receive payment from Medicare and agrees to accept payment from the PFFS MAO. HSA: A Health Savings Account in which yearly limited maximum contributions are made into the account by the member or their employer. The HSA is used for medical expenses not covered by the member's health plan or in which the member has a high deductible. HRA: A Health Reimbursement Account is an employer funded plan that will reimburse employees for health care expenses not covered by the employer's health insurance plan. COBRA: Consolidated Omnibus Budget Reconciliation Act is a federal regulation that allows employees and certain dependents to continue their group health insurance coverage for a set period of time when coverage is lost following a qualified event (job termination, reduced work hours.

7 Understanding the Verification Verbiage Determination/Verification of Benefits: Means you have verified and confirmed with the carrier specific benefits that are available based on the patient's health benefit plan. Determination of benefits is not a guarantee of payment. Pre-Certification: Means you can perform a specific procedure, but it is not a guarantee of payment. Prior Authorization: Means you will be paid for the service. Prior authorization from the carrier has to be obtained and provided in writing. Prior Authorization is a guarantee for payment. What is a PCP: A PCP is a family physician, family practioner or general practioner that is responsible for delivering or coordinating care. Participating Provider: A healthcare provider who has a written agreement (contract) with an insurance carrier to provide covered services to its members. Individual Deductible: The amount of money the patient is responsible to pay out of pocket before insurance company will start to pay. The deductible is usually paid once per calendar year (Jan-Dec) Family Deductible: Under this arrangement, if the designated number (2-3) of the family members meet the deductible in full then the deductible is deemed satisfied for all family members Annual Out of Pocket (OOP): This is a set dollar amount that the insured must pay for all medical costs before an insurance plan pays 100% of the bill. Copay: The fixed dollar amount that a patient is required to pay as their share of the cost of certain services each time they receive care from a participating provider Coinsurance: Cost-sharing requirement that the insured pay a designated percentage of the allowed amount for covered services. Carry Over Deductible: If an insured should meet their deductible in the last three months of the year, it will carry over (rollover) to the following year. (It is very rare that carriers provide this benefit). Maximum Lifetime Coverage: The maximum benefit amount that a carrier will pay out in an insured s lifetime. Once the maximum benefit amount has been reached, there is no longer any coverage available under that policy. Pre-Existing Condition Clause: Is a pre-existing condition that was in effect six months prior to the effective date of the policy. It can only be excluded for one year after the effective date of the policy. Exclusion: An item, service, procedure or diagnosis not covered by the carrier. Covered In-Network: What % of the services is covered if the provider is in-network? Covered Out-of-Network: What % of the services is covered if the provider is out-of-network?

8 Secondary Benefits COB: Coordination of Benefits is used to determine the order in which health insurance plans pay claims when more than one plan exists. If the secondary carrier is not aware that a primary carrier exists, you will not be able to determine the patient s responsibility. Notify the patient and ask them to update their carriers of the existing plans. Failure to do so will cause the claims to process incorrectly. Not being able to obtain correct COB benefits may also cause claim denials and/or delayed reimbursement. Collect the lesser of the co-pay of the two plans MSP: Medicare Secondary Payor, Medicare is secondary when a beneficiary is covered by a group health plan, Worker s Compensation, or other third-party liability coverage. To determine if Medicare Secondary Payor benefits are being applied correctly, reference the MLN Medicare Secondary Payor fact Sheet at:

9 Workers Compensation W/C: Workers' compensation is insurance coverage for an employee's injuries or illnesses arising out of the course of their employment. It is important to obtain authorization for treatment form the employer and carrier as soon as possible after the injury or illness had occurred. Not obtaining a claim number and all of the below information could result in claim denial or delay reimbursement. DOI: Date of Injury/Illness Brief Description of Injury/Illness DX: Diagnosis Place of Employment Employer Phone Number Supervisor Name Human Resources Contact Name Phone Number Insurance Company Name NCM: Nurse Case Manager Name Claims Address Phone Number If the carrier controverts the claim, they are denying it as not being work related.

10 Motor Vehicle Accident / PIP Personal Injury Protection Subrogation on Health Insurance Plans Subrogation means an insurance carrier will seek to recover reimbursement from the at-fault person or a legal entity for an accident after they monies have been paid out on behalf of their insured. The insurer becomes subrogated to the rights of your policy and can file a legal claim against the negligent party, your health insurance policy, or any other insurance carrier that would cover your treatment and care. You may be asked to sign a subrogation release that assigns your rights of recovery against the persons responsible for your loss. If the accident was your fault then you will be responsible for the damages caused in all or in part depending on the laws of your state. The other driver s insurance carrier will most likely subrogate against you and/or your insurance carrier to pay for property damages and medical costs. First-Party or Personal Injury Protection covers loss, damages and medical bills that are incurred by a policy owner or their passengers. Third-Party refers to the other person(s) that was involved in the MVA, motor vehicle accident. Third party liability insurance covers loss and damages to other people that are attributable to the policy owner. Third-party benefits may not be available until the claim(s) have settled. In addition to collecting MVA/PIP insurance benefits also obtain health insurance benefits should the MVA/PIP benefits exhaust. Know which party was at-fault in the MVA and ask the carrier if this applies to the determination of benefits. If the carrier DOES NOT subrogate, they may not pay for any of the accident claims. Be VERY specific when asking these questions. DOI: Date of Injury Brief Description of Injury Insurance Company Name Claims Address Phone Number (Ext) Claims Adjuster Name Do they Subrogate Deductible Was patient seen in the ER

11 Insurance Verification Exam 1) List as many plans that might require a referral: 2) What is the definition of subrogation? 3) What is a Pre-Existing Condition Clause? 4) What are five of the most common procedures done in a chiropractic office? List the procedures with the CPT Codes: 5) What does ICD-9 or DX stand for? 6) If a secondary carrier is not aware of the primary carrier, what should be done? 7) What information do you need about the provider before calling Medicare? 8) If the primary covers 80/20 and the secondary covers 80/20 of a procedure, how much is the patient s responsibility at the time of service? 9) What is a Letter of Credible Coverage and what it is used for? 10) When is Medicare secondary? 11) Why would a patient have COBRA insurance? 12) What should you do if you do not have the required information to obtain benefits? 13) What is the difference between an HMO and a PPO? 14) What is the scripting used for calling a secondary carrier for benefits? 15) What does an Exclusion mean in a plan policy?

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