Wiki Patients adamant about not paying toward deductible

[tworrock]

Hi all,

Since the new year has started and deductibles have reset, we've had a few patients swear up and down that they do not have to pay toward their deductible. I've personally never heard of this, and I've always had to pay towards my deductible. Can anyone shed some light on this? We are a specialist allergy, asthma, and immunology clinic.

 

[podcoder70]

Show them a copy of their benefits that you can print, usually, from your EHR at time of eligibility verification, or from the insurance portal. Make sure they don't have a Medicaid plan or a Tribal Health plan as secondary or that they don't have dual coverage. I suspect it is just a patient being difficult.

 

[tworrock]

Show them a copy of their benefits that you can print, usually, from your EHR at time of eligibility verification, or from the insurance portal. Make sure they don't have a Medicaid plan or a Tribal Health plan as secondary or that they don't have dual coverage. I suspect it is just a patient being difficult.

Thank you! So the problem I ran into yesterday was that Availity doesn't show this. Availity just shows a flat out deductible for all medical services. I ended up calling a few insurance plans to figure out the situation, and they said they will cover 100% of the OFFICE VISIT if the patient has a copay but NOT any additional services like testing or procedures... so that was news to me.

 

[amyjph]

It all goes by the specific plan and benefits for the individual patient. This is why in the revenue cycle it is 100% necessary to verify and check benefits before the patient comes in. January-March (or sometimes longer) is always a messy time in the process. Many (most) patients also have a really difficult time understanding insurance so you can't just go by "they said so". However, some of them really do know and understand their plan. I am always shocked when a provider doesn't want to collect my co-pay/deductible/coinsurance (that I know I have to pay) when I try to offer money at the time of service. They say oh we'll just bill you. It makes me cringe after being in this business for so long.

The moment a patient calls for an appointment and gets booked is the first time benefits should be verified and demographics collected, benefits should be checked again before they come in (depending on the time lapse between appointment scheduling and appointment date).

I have seen some weird plans like you mention above. Good job for checking around to make sure.

 

[Christal]

Hi all,

Since the new year has started and deductibles have reset, we've had a few patients swear up and down that they do not have to pay toward their deductible. I've personally never heard of this, and I've always had to pay towards my deductible. Can anyone shed some light on this? We are a specialist allergy, asthma, and immunology clinic.

When you call to verify the insurance benefits give them the codes for the testing, allergy injections, and serum mix. They can run the codes and tell you if those services are 100% covered, has copay/coinsurance, or goes to the deductible. We are an allergy office and we always verify benefits for new patients and follow ups, prior to their service. We give the codes for any testing or procedures we may perform and they tell us how the insurance will pay.

 

[sls314]

Thank you! So the problem I ran into yesterday was that Availity doesn't show this. Availity just shows a flat out deductible for all medical services. I ended up calling a few insurance plans to figure out the situation, and they said they will cover 100% of the OFFICE VISIT if the patient has a copay but NOT any additional services like testing or procedures... so that was news to me.

It's not surprising to me that an office visit with a flat rate copay isn't subject to deductible - that's the norm. A fixed copay for a service will often exclude that specific line item (like the E/M CPT) from deductible. Any other services done during the visit (testing, treatment, etc) could still be subject to deductible though.

Definitely still verify each patient's benefits, because there can be such variation between plan designs.

Also remember that sometimes plans don't go by calendar year for deductibles. The deductible for my employer's insurance plan runs from May 1 - April 30 based on our fiscal year. Our annual open enrollment happens in March. One of my past employers had a July 1 - June 30 deductible based on that employer's fiscal year. Just wanted to point that out in case you ever ran into that scenario when verifying benefits too.

There's always something to keep us on our toes!