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Eligibility and Benefit Pitfalls to Avoid

In the first part of the year there is a lot of activity around benefits and eligibility. During this part of the year kids are getting back in the swing of things and the holidays can be hard for some. Therefore, the need for therapy increases for a large portion of the population, but the problem that is presented is a lack of knowledge around how insurance works and getting accurate insurance information. This is also the time of the year that people are starting new jobs, receiving new insurance cards in the mail, and are shuffling in the economy. Since there are a lot of moving parts to the beginning of the year, we wanted to direct your attention to some eligibility and benefit pitfalls to avoid so that you can get paid on time and your clients don’t have to worry about insurance.

Pitfall #1: Not asking if your client’s insurance has changed

This may seem like an obvious pitfall, but insurance changes from year to year. Sometimes insurance companies issue existing clients new insurance cards in the mail with a totally different insurance number. Even this year, a member of our team received a new insurance card in the mail and almost threw the letter away because they thought it was junk mail from the insurance company. Had this person done that all of their claims would have been denied since the number was completely different.

Your clients may do the same thing, so it is important to encourage them to know what their insurance number is and check to make sure that nothing has changed with their benefits or their insurance number. Asking your client if anything has changed with their insurance can be the only bit of encouragement that they need in order to give you the best information possible so that claims go through without a hitch.

The other bit of information you may be looking for from your client is whether they have a bigger or smaller deductible. With the advent of high deductible health plans, your client may have opted to have a bigger deductible and a smaller monthly premium. You need to know if that has changed since it will alter how many payments they will make before insurance starts paying on their claims.

Avoiding this pitfall means that you are seeking to bring as much clarity as possible to your clients and give them the best experience possible when it comes to their eligibility and benefits!

Pitfall #2: Not checking to see if your client’s deductible runs on a calendar year or a plan year

This small detail often traps even the most competent of private practitioners. Deductibles reset on one of two possible cycles. The first cycle that a deductible can reset on is a plan year. That means that the deductible resets mid-year. For example, a client with a plan year deductible could run from July 1 to June 30, instead of January 1 to December 31.

A deductible that resets on a calendar year runs from January 1 to December 31. This means that deductibles start over and the client now owes the contracted rate of the session.

This detail is important because it helps you know what you should charge your client and it helps your client know how they should be budgeting for your services for the duration of the deductible. The point of avoiding this pitfall is to clarify the payment expectations for your clients so they are not surprised by the bills that they will receive from your practice.

Pitfall #3: Not collecting pictures of insurance cards

This pitfall to avoid is really a pitfall to avoid all year long. For all of your clients, a standard operating procedure is to collect a picture of the insurance card (both front and back). The reason for collecting a picture of the insurance card is two fold.

The first reason you need a picture of the front and back of the client’s insurance card is to make sure that whoever is doing the billing has the correct information in case they need to contact the insurance company. Because insurance companies are large organizations that off-shore their call centers, you will need to ensure that you have the correct phone number so that your staff is not wasting time.

Having a copy of the insurance card ensures that you are operating as efficiently as possible so that your practice can be paid on time.

The second reason you need a picture of the front and back of the client’s insurance card is to make sure that the client’s information is on the claim properly. Since people are errant there are times when they don’t include the correct information on the intake paperwork. An insurance card ensures that the correct information is on the claims that are sent out of the EHR system that you are using.

It is important that you have a copy of the insurance card so that you know who to contact if there are issues with the claims and if you need to verify that the information that was sent out on the claims is correct.


All in all, eligibility and benefits can be a difficult process to execute since the insurance companies can be complicated to work with. However, it is important that your process for eligibility and benefits is clear and consistent. The better your eligibility and benefits run the smoother your practice will run and the faster your practice should be paid.

If you are having issues with your eligibility and benefits, feel free to reach out and a member of our team would be happy to talk you through the solutions that we offer to help your practice run effectively and efficiently.

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