End of Year Housekeeping: Best Practices for Verifying Benefits and Managing Patient Credits in Your Practice

As we approach the end of the calendar year, verifying a client’s benefits for out-of-pocket (OOP) maximums is essential to ending the year well and beginning the new year on solid footing. You may be familiar with verifying general benefits, but identifying where your clients stand within their OOP limit is essential for accurate billing. Understanding how much a client has paid toward their OOP maximum ensures your practice charges appropriately, especially toward the end of the year.

Understanding the Importance of Verifying OOP Accumulations

An out-of-pocket maximum is the total amount a client must pay in a given year for deductibles, copayments, and coinsurance. Once this maximum is met, the insurance plan typically covers 100% of covered services. Make it a standard practice to verify the OOP accumulation at every visit or regular intervals to ensure they don’t inadvertently charge clients after reaching this maximum. 

Practice Solutions recommends this as a proactive step. Building consistency in verifications protects against claim denials, commonly linked to billing errors and improper benefit assessment. We assist with verifying accumulations upon request as part of our billing services. 

Communicating OOP Status with Clients

Clear communication with clients regarding their OOP status is also a best practice that builds trust. During intake, make it a point to inform clients about their financial responsibilities and explain that you will be monitoring their OOP status to ensure they aren’t overcharged. Regularly updating clients if they are nearing their OOP limit can also be a positive way to keep them engaged and informed, and it assures them that your practice is organized and proactive.

Providing clients with a summary of their benefits or a record of their accumulations (if accessible) can reduce confusion. If a client’s OOP limit is approaching, encourage them to contact their insurance company directly to confirm their status, giving them additional peace of mind.

What to Do When a Client’s OOP Maximum Has Been Met

When a client has met their OOP maximum, your next step is to avoid collecting further payments. Clients who have met their maximum should not be responsible for copayments, coinsurance, or deductibles for covered services. Sometimes, clients may unknowingly continue to make payments after their maximum OOP. This happens if the insurance company’s update on the OOP status is delayed. If this occurs, you will need to refund clients promptly to prevent misunderstandings or frustration. Keeping an organized ledger or using billing software that tracks payments and flags anomalies can make handling these situations preventable.

With Practice Solutions billing services, you can be sure that insurance payments are posted regularly and accurately to help have a clear picture of client account balances. 

Handling Patient Credits and Refunds

Refunding overpayments is an ethical and financial necessity. Not only does it maintain transparency, but it also solidifies the relationship of trust and respect you have built with your clients. If an audit reveals that a client overpaid, send a clear and concise message explaining the situation and how the refund will be processed. Most billing software allows for easy adjustments and notes on patient accounts, which helps streamline this process. Document all communications around credits and refunds to avoid confusion and demonstrate your commitment to transparency.

Creating a Reliable Verification Workflow

Establish a systematic approach to verifying benefits, especially concerning the OOP maximum, at regular intervals to keep everything in check. A few key touchpoints include verifying before the first visit, during major plan renewals or changes, and upon client requests. Ensuring these checks are documented in the client’s record can minimize errors and streamline future interactions.

Using a consistent verification protocol demonstrates that your practice takes client finances seriously. Many billing consultants emphasize that creating a workflow for benefit verification and OOP tracking protects the client and provider from unnecessary financial disputes.

Practice Solutions has options for your practice to establish a reliable verification workflow. With billing services, verification of benefits can be managed by your biller. With professional services, we can examine your practice and make recommendations to help you build workflows within your practice. 

Conclusion

Verifying benefits to find accumulations for the OOP maximum is a foundational best practice for any health practice that values transparency, client satisfaction, and financial integrity. Understanding a client’s OOP maximum status safeguards your practice from errors and protects clients from potential overcharges. Developing a systematic approach to benefits verification, clear communication, and an efficient credit handling process provides a professional and supportive client experience. With these best practices in place, providers can confidently build a loyal client base that trusts them with their care and financial security.

Practice Solutions can be a valuable partner as you manage verification of benefits and patient credits. Reach out to us today to see which solution is right for you!