Most patient’s benefits start over at the beginning of the year. A small handful have a “benefit” year which is something other than a calendar year, typically July to June. For those that have the majority calendar year policies, this means deductibles will re-start in the new year (if you submit a claim in 2012 for dates of service in 2011, they still process with 2011 and will not go towards the 2012 deductible). Since many of you don’t deal with the details of insurance often, I will give you some reminders of what happens in the new year. First, all patient’s insurance benefits should be re-verified at the beginning of each year. In my offices, we get “update” forms just to re-verify addresses, phone #, etc. and get a NEW copy of insurance cards. Many people will tell you none of this has changed, maybe that’s true, but for those you catch who moved, etc. and have completely new information, you will be glad you went to the trouble. It’s prudent to always get new insurance cards since sometimes subtle changes occur to policies; higher deductibles, ID number changes, etc. When you call to verify insurance, make sure to use a form. We have one on the website for you to use as a template (Health Insurance Verification Form). It’s important to get all questions answered and if you simply jot down the info they tell you, as they ramble it, you may miss out on some important details.
Deductibles: this is the amount a patient must first pay before their insurance benefits kick in, however, HOW visits are applied to deductibles can be tricky. For example, when you bill Anthem Blue Cross, most of the time, they will pay a max of $30-$33/visit…well, this is also the amount they will apply to someones deductible. Whatever the amount the insurance would typically PAY is what gets APPLIED towards their deductible. Keep this in mind. So, for someone who has a $250 deductible, for example, it would take about 8 visits to meet the deductible at the above mentioned rate with Anthem. Once the patient’s deductible is satisfied, you then begin charging either co-pays or co-insurance.
A quick benefit reminder on co-pays versus co-insurance. When you are quoted that a patient has a co-pay, this is a SET amount they pay per visit versus a % coverage, for example when they say the patient has a 20% co-insurance. This means that, of the ALLOWED amount, the patient is responsible for 20% and the insurance covers 80%. With United healthcare, for example, they typically allow $72/visit. If the patient has a 20% co-insurance, they are responsible for about $14.40 per visit while the insurance will then pay the difference ($72-14.40) or $57.60. They may say they cover 100% with a $10 co-pay, this means that in the above situation where they allow $72.00 they would pay $62 or the amount after the patient pays their $10 co-pay. Most often it’s a one or the other scenario, it’s either a co-pay or a co-insurance, not both.
To summarize, at the beginning of the year you need to:
- Get new copies of insurance cards
- Re-verify patient’s insurance
- Collect from patients who are meeting a deductible
- From how much is applied to the deductible, you can determine 1) how many visits it should take to meet the deductible and 2) make a good guess at how much the patient’s co-insurance will be, if this is how benefits were quoted.
I hope you found this information helpful. If you have any questions, please make sure to leave a comment on the site and I’ll do my best to address it.