Accepting Insurance 101 Part One of Part One – Verifying Coverage

I have been meaning to write something that gives step-by-step instructions on how to accept insurance in one’s practice for some time. My problem is keeping things simple; I tend to be uncomfortable with leaving any details out for simplicity’s sake and that makes me hold-back until I have time to cover a subject in detail. In thinking about the issue of accepting insurance, I decided to break it down into more than one posting or else I might never get to it so here goes –

There are two broad categories of the types of insurance you will have the chance to work with in an acupuncture practice – the first is insurance systems that you have no written contract or agreement spelling-out your rights and responsibilities and the second is when you do have such an agreement. This posting will cover the first type in which you are not under an agreement with an insurance company such as an HMO Network or any type of Provider Panel. I will further break this type down with this first post being how to verify coverage and then the next post will be how you bill.

When you are under an agreement with and insurance company or companies, you will be able to find details of just how you are supposed to deal with them. I will explain more on that in another posting when I cover those types of Plans. Otherwise, if a patient comes to you and they have insurance that you are not under an agreement for, you are going to try to work with the patient and their insurance plan. The patient (perhaps through their employer) has an agreement with their insurance company but you do not so you have no leverage with the insurance company. You can and should have some leverage with the patient. Just because you agree to bill their insurance does not mean that the patient is off the hook for paying for your services. They are in essence a cash patient and they are liable to pay you for your services, but here you are offering to bill their insurance directly in order to make payment easier for them (and encourage them to use your services with less financial stress).  

By far – the most important thing you need to learn in order to take-on this type of insurance patient is if their insurance will pay for your services under their Plan. This is called “verifying benefits” and the only way to do so is to call the patient’s insurance company and ask. You will need to give them specific information I will go over below. Most of the patient’s information you will need to give their insurance company can be found on their insurance card so you should get that or make a copy of that (both sides). It should have a phone number that you can call. This will be a “provider’s” phone number rather than the “member’s” phone number on the card. It is best to have your own form that you will use to ask the questions you need to get answered and write those down as you check them off and keep that in the patient’s file. I will get our form available on this site for downloading but may take me some time to get that done.

The following is a list of information you will need to be ready to give – although not all insurance companies will ask for all of these. Most of this will be on the insurance card but, if not, get it from the patient. Information needed to verify benefits:

The patient’s full name (including middle initial), date of birth, address and perhaps employer if the patient is the “insured”.

If the patient is not the one who insurance plan you are checking on (it may be the spouse’s insurance plan), you will need the INSURED’s name, date of birth, address, and name of employer.

You will also need any Plan or Group numbers or any type of numbers identifying the patient, the insured, or the insurance Plan itself. Sometimes, the “member’s (insured’s)” number will be their Social Security number but this is less the case today.

You will also need to be ready to tell the insurance company representative what type of medical condition you are seeing the patient for. You can usually tell them the name of a condition such as “ low back pain” but you also want to be ready to tell them the diagnosis (ICD-9) number such as 724.2 for low back pain.

Your Phone Call to the Patient’s Insurance Company:

When you call the Provider number tell the representative – “ This is a provider of services’ office and I am calling to verify benefits for this patient, specifically to see if this plan covers acupuncture by a Licensed Acupuncturist.” 

They will then ask you for some identifying information – the patient’s name or the insured name or the Group or Member number, etc. They may also ask for the employer. Once they ask their questions of you, they should then start to tell you if the plan covers acupuncture of not. If they say there is no coverage for acupuncture that is all you need to know but you should always ask the representative for their name and write that down. If they say there is coverage you need to ask some more follow-up questions such as:

Is there a deductible?  If so, has it been met? If not, how much is has been charged toward the deductible?

Is there a limit to the number of treatments allowed per year? If so, is that total per year or per condition treated?

Is there a list of covered conditions?

Does there need to be a referral from a Primary Care Physician?

Are there any specific exclusions or limitations?

What is the name of the representative?

While getting the above information should tell you what you need to know about just what your patient’s insurance company will do with your claim when you send in your bill, the unfortunate fact is you cannot always rely on the information you were given being honored. Sometimes the insurance company will respond to your bill with policies that are not in-line with what you were told. This is very frustrating but it can happen so don’t think the information you were given is an absolute assurance of what the insurance company will honor. The best you can do to reduce the damage of this happening is to have your patient sign an agreement that says they understand you did what you could do to verify their insurance coverage but if for any reason your bills are not paid by the insurance company, the patient agrees to pay you themselves. This not only gives you some protection if the insurance company tries to deny your claim (bill), it also helps to protect you if your patient loses their coverage while being treated by you and conveniently forgets  to tell you about that. I will try to get a copy of the form we use for this up and available on this site for downloading too.  

OK – I think that is enough for now. If there is enough interest, maybe we can organize a conference call to verbally go into detail on insurance matters. I will make another post as soon as I can about how to actually bill for your services. In the meantime, as always, your question on the above are welcomed. 

Matthew Bauer

Thank you, that is so helpful!  I’ve been searching for clear, concise info like this.  I’m looking forward to the next piece of how to bill for the services-copays, etc.  Also, I’ve always wanted to know how to submit a superbill for them, through a system like office ally.  Is there an easier way?

Thank you!