Billing Success Begins With Insurance Verification

Insurance verification is necessary to determine the validity of the patient’s coverage with the third-party payer, and to establish the patient’s financial responsibility (e.g., co-insurance, co-pay, deductible, and annual out-of-pocket limits).

Staff responsible for insurance verification should review the provider’s schedule daily to identify scheduled new patients prior to their appointments. Several days in advance of the appointment, the patient should be contacted to obtain the following insurance information needed for verification purposes: name of third-party payer, verification phone number, member’s name, member’s ID, and member’s date of birth.

If a patient is “in network,” coverage should be verified. This step also should be completed for all patients (new and established) at the beginning of the calendar year, or anytime the patient’s coverage changes. For Medicaid patients, an additional verification should be performed prior to each appointment. This additional verification will assist in identifying any changes in the patient’s Medicaid plan since the last visit.

Insurance verification may be performed over the telephone, while the patient is scheduling an appointment, or via online systems. Always retain proof of insurance verification, either electronically or within the patient’s chart.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 402 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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