What You Need From The Patient

It really does take a village, the patient, the provider and the health carrier, to get a claim from initial encounter to electronic payment (or paper check).  

It all starts with paperwork, you need:

  • A copy of the patient's insurance Identification card front and back.
  • Completed health history forms.
  • HIPAA forms that clearly state the office privacy policy including how the Protected Health Information (PHI) will be handled.
  • A completed Assignment of Benefits form with a signature of the patient or guardian authorizing the insurance carrier to pay the doctor, not the patient, for all billed services.
  • A completed Release of Information form with a signature of the patient or guardian giving the provider the permission to release information about the patient's medical condition and treatment to anyone with the need to know. The types of people that would need to know would be the insurance carrier, any specialists etc.
  • A completed Advanced Beneficiary Notice (ABN) form with a signature from a Medicare beneficiary when you have reason to believe that Medicare may not pay for the service that you are rendering to the patient. This form advises the patient of any potentially not covered service and by signature they can indicate whether they want to proceed with the service and whether or not to bill Medicare. No ABN is needed for services that you know are not covered by Medicare.
  • Patients who are willing to jump in, arms swinging, to help resolve any issue that may affect the provider's and ultimately the patient's pocket.

Patients Are Our Best Resource

I believe that patients should have the kind of relationship with their health care providers that promote comfort, communication and confidence. All expectations should be clear, from both sides, with no surprises. Patients should be kept in the loop regarding any issue that affects their healthcare or their health insurance.

Patients can be the best resource when you have hit a brick wall on an unresolved claim issue. One call from the patient may help you to:

  • Move a claim from pending to payment. 
  • Resolve a payment problem or dispute.  
  • Solve a plan, benefit or coverage issue. 

A bit of pressure from the patient may work the magic that is needed to finally get that problem claim issue resolved. Health insurance carriers do not like to have unhappy, “I am going to complain about your service to my boss,” type of plan members that may affect business.  

Real world example

A very young patient, with medical issues, was in urgent need of some extensive therapy. The parents are divorced and the child resides with the mom. The divorce decree mandated that the father’s coverage be primary and the mom’s coverage be secondary.

We had contacted both health carriers, in advance, and was granted out of network approval from the dad’s plan and in net approval from the mom’s plan. The services were performed and the dad’s plan was billed.

Weeks later, I call to check status on this unpaid claim and learn that a payment of $4200.00 was made directly to the dad. Because we are an out of network provider, the health carrier refused to provide a copy of the EOB or to provide any other details about this claim.

I contacted the mom for assistance, informing her that we needed two things; the $4200.00 payment and the EOB so that I could bill the secondary plan for the balance. She contacted her ex-husband and yes he had received the check and no he did not have the money as he used it to put a down payment on a new truck. He also refused to provide a copy of the EOB to mom.

Mom asked that I give her three months to get this resolved. I agree and her account was flagged for follow up in 90 days.

About 2 months later, the mom called me back. She had sued her ex-husband and because of the child’s medical needs and was granted an emergency hearing. Not only was dad ordered to pay the $4200.00 payment immediately and provide us with a copy of the EOB, he ended up paying all of her court costs and was threatened with jail time if this happened again.

This issue would never have been resolved had the mom not jumped in to help. Resolution was critical so that further access to care was not affected. 

Back to Chapter Five

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