Claims Prep 1 Checkpoint Week 3

One factor that determines a patient’s eligibility of benefits is whether or not the planned office visit is covered. To determine this, the medical specialist from the insurance company has to see if the visit is covered. If it is, then there are no issues. If the doctor visit is not covered by the insurance, then the agent must inform the patient of this and make them aware of the financial responsibility at hand. They must do this before the scheduled appointment takes place.   Usually, medical insurance specialists already know which plans cover what services, so they are on top of letting the patient know what is going on ahead of time.   When a patient is not covered, there are certain steps that need to be taken. The first step is to discuss the situation with the patient, as described above. Then, the payers have the physicians give the patient a form explaining the finances at hand. The patient must then sign these forms, agreeing to the terms of service. This also covers the insurance company and physicians in the case a lawsuit would be filed. The next step is that the managed care payer requires preauthorization before the patient is cared for. If the service is approved, then an authorization number is given and has to be entered in the practice management program. Sometimes, a physician refers the patient to another physician for evaluation of their condition. An example of this would be an internist sending a patient to a cardiologist for a heart condition. A referral number and document is given, and this means the patient brings the document and number with them to the visit. Finally, a primary insurance is determined, meaning the specialist sees if there is another plan that covers the service. This is called filling-the- gap.
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