What to Look For In a Verification of Benefits
Look out for deductible information
Look out for copay information
Look out for out of pocket information
As you are creating your verification of benefits process (VOB) you will want to be on the look out for a variety of different information. One of the best ways to help eliminate the complexity of information is to create a standardized form that includes the information in this blog. At the end, we will give you an example form that you can use in your practice.
Since verification of benefits can include a wealth of information, you will want to be on the look out for very specific information and you will want to document that information in a unified format.
Before you get started there are a few items that you will want to prepare. Make sure that you follow this checklist before beginning your eligibility and benefit check:
A copy of the patient's insurance card, both the front of the card and the back of the card
The number to call from the back of the insurance card. If it specifies which benefit (i.e. mental health) you will want to contact that number.
The patient's first name, last name, and date of birth. This information will need to match exactly what is on the patient's insurance card
A form template for capturing the insurance information that you are going to collect
Leave room in your schedule to be on the phone for about 40 minutes per eligibility and benefits call
Look out for deductible information, copay information, and out of pocket information. Let's say you are on the phone with an insurance representative and you are trying to figure out what the patient owes and what the insurance owes. You will want to find the following information:
A deductible is the amount that a patient owes for care before the insurance company will pay for services. Therefore, when a patient has a deductible, they will be responsible for the entire amount of the session before the insurance company will pay anything.
For example, if a patient has a $3,000.00 deductible and your allowable amount is $100.00, the patient will have 30 sessions paying $100.00 before the insurance company pays anything.
Copay or Coinsurance Information
A copay or coinsurance is the amount that a patient owes after the deductible is met. Therefore, if a patient has a $20.00 copay after their deductible, the patient will pay $20.00 per session after they have met their deductible.
Or if a patient has a coinsurance, they will owe a percentage of the allowable amount. For example, a patient have have an 80/20 plan where the insurance plan will pay 80% of the allowable and the patient will owe 20%.
Therefore, if your allowable amount is $100.00 then the patient is going to pay $20.00 and the insurance will pay $80.00.
What if your allowable is a strange number? That is a good question!
If your allowable is a funny number like $101.32 and the patient owes a 20% coinsurance you would multiply $101.32 by .20 to get the patient amount. So....
$101.32 X .20 = $20.26
So you would charge your patient $20.26
Out-of-Pocket Maximum Information
An out-of-pocket maximum amount is the TOTAL amount that the patient should pay for medical services in a given year. Once the patient reaches this amount, they should owe exactly $0.00 for your services for the rest of the plan year.
This is number is usually very high. It is not uncommon for an out-of-pocket maximum to reach or exceed $5,000.00 or $10,000.00. However, all medical expenses count toward the out of pocket maximum.
Therefore, it is not uncommon to have patients start treatment in August, September, or October that owe $0.00 out of pocket for your services.
NOTE OF CAUTION: Be sure to monitor how those claims process, because if the insurance company doesn't pay, that could lead to free services
Other than this information, it is important to look for the following information:
Whether authorization is needed for your codes
When the plan is effective and when it terminates
The reference number of the call you had
The number you called to get benefits
The name of the rep that you spoke with
VOBs and getting information that you need in order to properly bill can be difficult, but creating a clear system and process of getting that information is sacrosanct to your mission of providing excellent services to patients.
Here is an example of an eligibility check form that you can use for your practice:
Updated as of: TODAY'S DATE
Deductible: Amount of the deductible met:
Out of Pocket Maximum:
Amount of the OOP met:
Authorization needed for code 11111: Yes or No: