Now is the Time to Expand Your Verification of Benefits Form

Appealing Observation Level of Care Denials

Under constant pressure to avoid unnecessary inpatient admission, observational care is growing in many regions. Further, many organizations are seeking ways to expand their observation care units to include more specialized personnel and equipment and intensive patient education programs.

Are your payers rolling out new tactics to avoid releasing claim payments? It may be time to enhance your verification of benefits to insure that emerging claim processing tactics are identified. Early identification of the effects of pay-the-patient initiatives, high deductibles and tighter utilization review controls should be a goal in your verification of benefits routine. Now is a good time to make sure your medical organization’s verification process is sufficiently thorough to identify these factors. As follows are the top five recommended changes you may want to make to your verification of benefits process:

1. Demand disclosure of anti-assignment provisions. Medical organizations rely on payers honoring assignments. However, carriers are testing direct payment initiatives, also known as pay-the-patient, in many regions. Therefore, it is important to ask prior to treatment is the assignment will be honored. If the payer will not honor the assignment, ask that the anti-assignment clause be faxed to you for your records. Insurance carriers may balk at providing such information. However, if you put your demand in writing, the insurers may be obligated to respond in compliance with potentially applicable state and federal disclosure laws.
2. Demand disclosure of deductible calculations provisions. Most verification forms include a blank where the insurance verifier writes in the amount of the deductible. However, a number of follow-up questions are pertinent due to the emergence of various deductible calculation scenarios. Some of the pertinent follow-up questions to add to the form include seeking information on what is exempt from the deductible, such as preventative care, how much has been used and if the yearly calculation will carry over any previous year patient expenditures.
3. Demand disclosure of fee schedule or usual, customary, reasonable calculation for upcoming care. Because benefits vary greatly from policy to policy, it is important to seek an actual “quote” regarding how much will be paid for scheduled care. If the carrier states that such detailed benefit information is not available prior to receipt of the bill, put the request in writing and submit it with a copy of the assignment of benefits. As indicated above, written requests for benefit information may fall under state and federal disclosure laws which require insurers to be forthcoming with specifics regarding coverage.
4. Demand disclosure of the carrier’s utilization review accreditation. If the carrier is accredited by the Utilization Review Accreditation Commission (URAC.org), they will have to follow strict procedures for decision making and must provide certain information, such as credentials of the reviewer and clinical review criteria, upon request. If they utilization review personnel are unaccredited, this serves as a red flag.
5. Follow up the verification phone call with a written request for benefit disclosure. Insurers frequently state that the verification is not a guarantee of payment. If incorrect information is given by the carrier, the medical organization often has limited recourse against the carrier. However, a medical organization which submits a written request and provides the assignment of benefits to establish a right to benefit disclosure may have firmer legal grounds for pursing legal action based on misrepresentation of benefits and/or failure to properly disclose benefit information.