Billing Process

Eligibility, Payment, and Billing Procedures
Lynda Wilson
March 1, 2012
Felicia Pettit-Wallace

Eligibility, Payment, and Billing Procedures
A factor that would describe a patient’s eligibility has many to choose from the factor that I find quite common is the patients that have the employer –sponsored health plans where the employment status determines if they are actually eligible. In most cases as long as an employee is working full time benefits are covered, but as soon as the employee goes to part time the benefits are stopped.
Some steps that can be taken when patients insurances do not cover a planned service is the job of the medical insurance specialist, it is their job to make sure that if the planed service is not covered that the patient be notified as soon as possible of the financial responsibility.   The medical insurance specialist also uses a form that explains the patients responsibility financially and the patient has to sign stating that they were aware that payment is due before the procedure can be done. Also checking out-of-network benefits and verifying the amount of the co-pay is important when determining whether the patients plan covers the services they are receiving.
The eligibility factor I identified relate to these steps because if the patient is no longer employed or the employees child has become of age then it is strictly on the patient to pay for financial services before they are rendered. A couple patient charges that may not be covered and have to be checked for coverage are psychiatric visits and or office visits. These must be checked to make sure that the patient is covered and or can pay before the services are rendered.   The medical insurance specialist has to determine if there are any out-of-network expenses that the patient must pay and also verify the co-payment upfront to make sure it is correct.