Document this when speaking with payer
The fact that payers almost never give a guarantee of payment prior to service and require registrars to confirm that there is no guarantee “should set off warning bells when verifying coverage information,” says John T. Porter Jr., access denial analyst for patient financial services at Scripps Health in San Diego, CA.
“Our job is to corner them into the closest thing to a guarantee as possible,” Porter says.
In addition to documenting the Healthcare Common Procedure Coding System (HCPCS), Current Procedural Terminology (CPT), and International Classification of Diseases (ICD-9) codes that were provided to obtain coverage determination, Porter says to document these items:
• name of insurance company contacted;
• person contacted;
• date contacted;
• call reference number;
• insurance effective date;
• date of service reported;
• contracted provider (yes/no);
• service type quoted;
• benefit category quoted;
• CPT codes checked;
• Utilization review (UR)/pre-cert required (yes/no);
• UR/pre-cert phone number;
• independent practice association (IPA) name (if a health maintenance organization);
• IPA effective date;
• authorization responsibility: IPA or health plan?
• deductible;
• deductible met (yes/no);
• co-pay or coinsurance;
• claim mailing address;
• verified (yes/no);
• maximum allowable for service;
• out-of-pocket maximum;
• lifetime maximum;
• annual maximum.
“Payers tend to dictate what information is given, and a checklist will guarantee all bases are covered,” Porter says. “This documented information is important because it can be used to overturn a denial.”
The fact that payers almost never give a guarantee of payment prior to service and require registrars to confirm that there is no guarantee should set off warning bells when verifying coverage information, says John T. Porter Jr., access denial analyst for patient financial services at Scripps Health in San Diego, CA.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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