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  • Practice Solutions

How to Explain Benefits to a Patient


Main Points

  • When explaining benefits to a patient it is important to start with the facts

  • When explaining benefits to a patient is is important to be transparent with the process

  • When explaining benefits to a patient it is important to give them their options

This is where the rubber meets the road. Explaining benefits to a patient can feel like teaching a pig to sing. Regardless, it is very important that both clinicians and patients have a clear understanding of the insurance benefits and how claims might process.

Bear in mind that verification of benefits are correct 70% of the time. That means that 1 out of every 3 eligibility checks are incorrect, and that is based on the insurance company information not the person doing the eligibility check.

Since eligibility and benefits checks are not always correct, don't guarantee that the claims will process according to the eligibility check, but rather take the following steps to communicate benefit information to patients.

When explaining benefits to a patient it is important to start with the facts. Start with what you know from the call that was made to the patient or from what was gathered off of an online payer portal.

Online payer portals can be a great way to objectively show a patient what their benefits might be. Some examples of payer portals are:

  • Web-Denis

  • Availity

  • CHAMPS

  • Navinet

Taking screenshots of the benefit information that shows up on these portals can be a good way to visually represent what the patient might owe for their benefits.

If you called the insurance company and kept notes, then you can share those with the patient. Be clear with them what you found and tell them what you did to get that information.

When explaining benefits to a patient is is important to be transparent with the process. Tell the patient exactly what steps you took to get the information that you did. First, this will help you stay accountable to your own process. Second, this will help the patient to feel that you are on their side in accomplishing a shared objective of securing payment for services and thus ensuring that treatment continues.

You will want to take the patient through the process. This could include:

Giving the patient the number you called

Telling them the name of the rep you spoke with

Reviewing the information you were given

Giving the patient their benefit information in a consumable format

It might go without saying, but it is important to clarify that your patient understands their benefits and knows what the financial risk might be if the claims process differently than the insurance company told you.

When explaining benefits to a patient it is important to give them their options. Let's say you do an eligibility check and you have explained the benefits to the patient, but then the patient disagrees with what you found or the claims process adversely to the benefit check.

What then? What do you say to someone when you have gone through a bunch of work and you are now hitting roadblocks?

There are a couple of options:

First, give them all the information that you received from the benefit check and tell the patient to call their insurance company. Only 1% of patients dispute claim denials and out of that 1%, 70% receive an overturned denial.

You can give the patient the number that you called, the rep that you spoke with, and the reference number of your call. Then go through each of the elements of a benefit check and explain in detail what each facet of the eligibility check means.

This will help your patients to understand what their benefits are and how the claims might process.

Second, tell them that the eligibility is a quote of benefits given by the insurance company and that they are sometimes incorrect. Communicate to the patient that the goal here is to abide by the requirements of the insurance company and ensure that treatment continues.

Insurance companies and their processes are hard to understand and comprehend, especially if you are seeking mental health services or are in a crisis. So, it will important for both treatment and your bottom line, if the expectations are set at the beginning of treatment.

You wouldn't want to get down the road and then have to stop seeing the patient or have to refer them to someone else because the patient didn't understand that the benefits given were just a quote and not a guarantee of payment.

Third, if money is the issue, then you can always set up a payment plan so the patient can pay off their deductible over time, even after treatment has terminated. This is one of the most neglected strategies utilized by providers.

Ultimately, patients owe their deductible, and providers can get into a lot of trouble if they write off the deductible or copay balance without proving they have tried to collect the balance.

As the provider of service, you have the latitude to set up a payment arrangement with your patients so they don't have to go to collections and you don't have to suffer by not collecting the balances from your patients.

It is empowering to receive good information from the insurance company and have the claims process according to the benefits given. However, explaining this process to patients can be challenging and discouraging. Just remember, that dealing with insurance is not always cut and dry.

Clearly communicating to the patient what you think their benefits are and how claims might process is the first step to ensuring that your patient continues to pay for services.

If you feel that you need further assistance with this process or want to speak to someone about your eligibility process feel free to contact us here!

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