Wiki Compliance / Insurance and Patient Demographic


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Hello all,

I posted the following question in the Billing forum but thought I would see if I could gather any further information over here regarding compliance of the following scenario:

We are trying to get some guidance as to the following; occasionally, our billing staff encounter a situation where the patients’ insurance card or portal does not agree to the demographics entered into the practice management screen, such as date of birth or spelling of name.

Our current practice is to change the registration to match the insurance card and flag the front desk to contact the patient that their insurance company has different information, and that if the insurance company has the wrong information the patient needs to contact them to fix their record.

Although I believe this is the way this is handled at most practices, I do not know if it is considered best practice or if you have ever encountered anything official around this. I can’t find any specific guidance from an official source.

Input / suggestions / ideas?

Thanks in advance.
We actually do the same thing. But instead of flagging the front desk we actually call the patient and verbally update her on the issue and notate the A/R. That way its also documented for good measure.
You can't just change your demographics to match the insurance card. You need to determine which info is correct and if the insurance has the wrong info the patient needs to contact them and correct it.
I disagree wtih khristinelouise. Even though the patient asks the insurance to correct the information, they may not do it. (We've had patients who have fought with their plans over this and never go a resolution.) Since claims may be rejected or denied if your demographics don't match the insurance's, you have no choice but to match your demographics to theirs, even though theirs are incorrect.

There is actually a way to "have it both ways." You can enter the patient's demographics accurately, then enter a separate "subscriber" who is actually the same person, but with the insurance's version of the demographics.
I don't know of any official guidelines on this one way or the other, but I would add that this is an area where some caution is essential due to the possibility of identity theft or inappropriate sharing of medical insurance benefits. Discrepancies between insurance and patient demographics do occur, but I think that in these cases it's important to take some additional steps, such as requiring and documenting some additional form of photo identification, to ensure that the person who is receiving services is the same person for whom you will be billing for payment of benefits.
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It seems to me that to change a persons legal name or DOB simply to get paid is unethical. I have looked for official guidance on this and never found anything one way or another so maybe it's just me. I know I can be a bit inflexible about these types of issues but I feel that it is the patients responsibility to make sure that their insurance has their demographics correct and to fix it if they don't. In our practice if the insurance denies the claim because of this we put it to patient responsibility and it's amazing how quickly a patient will get it fixed.