Verifying your patients’ eligibility and benefits in 2015 may save your practice thousands of dollars

December 04, 2014

With the new year soon upon us, physicians are urged to be diligent in verifying patients' eligibility and benefits to ensure that you will be paid for services rendered. The beginning of a new year means calendar year deductibles and visit frequency limitations start over. With open enrollment there may also be changes to patients’ benefit plans, or they may even be insured through a new payor.

The new year also brings a host of other challenges that could affect your ability to be paid:

  • Medicare patients can modify their enrollment choices from October 15 through December 7, allowing them to switch between Medicare fee-for-service and Medicare Advantage, or switch from one Advantage plan to another.
  • The Covered California open enrollment period is November 15, 2014, through February 15, 2015. Existing exchange/mirror patients have the option to select a different plan and Covered California expects an additional 500,000 individuals will enroll in an exchange plan during 2015 open enrollment.

Additionally, there will be some changes to exchange/mirror product names in 2015. Covered California notified all exchange plans that the product names must be the same for exchange and mirror products and that plans must also utilize a standard naming convention for all individual exchange/mirror products.

  • California moved the remaining 25,000 seniors and persons with disabilities (SPDs) from fee-for service to managed care on December 1, 2014, in the following counties: Alpine, Amador, Butte, Calaveras, Colusa, El Dorado, Glenn, Imperial, Inyo, Mariposa, Mono, Nevada, Placer, Plumas, San Benito, Sierra, Sutter, Tehama, Tuolumne and Yuba.

Additionally, 30,000 patients who are dually eligible for Medicare and Medi-Cal in Los Angeles and Santa Clara counties will begin to transition from fee-for-service Medicare and Medi-Cal into managed care on January 1, 2015. Dual eligible enrollees will transition in these two counties over the next 12 months based on month of birth. Duals will also continue to transition based on month of birth in San Bernardino, Riverside and San Diego counties. The duals transition for Orange County is scheduled to begin in July. For more information on Duals, see CMA’s toolkit, “Cal MediConnect Physician FAQ &ndash.

Don’t get stuck with unnecessary denials or an upset patient. Do your homework before the patient arrives by obtaining updated insurance information at the time of scheduling, if possible, and making copies of the insurance card at the time of the visit.

And don't forget that deductibles are typically based on the calendar year and will reset on January 1. Many of the exchange/mirror plans have high deductibles (e.g., $5,000 deductible on the Bronze plan), as do some employer-based plans. This reinforces the importance of verifying patient eligibility – particularly for exchange patients – each time they are seen. Best practice is to communicate with patients upon scheduling to remind them that their plan has a deductible that may be resetting on January 1 and, if that is the case, payment will be due at the time of service. If you offer an appointment reminder service, remind the patient if payment is expected at the time of service. Failure to collect deductibles, copays and coinsurance at the time of service can be very costly for a practice as your ability to collect can decrease significantly after the patient leaves the office.

Taking these proactive steps to protect your practice by preventing denials, delays in payment and disgruntled patients goes a long way toward ultimately saving time and money. 



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