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Claims Management Tip: When Your Payer Does Not Cover Service

Posted by Sharon Chin on Dec 8, 2015 10:00:00 AM
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Making sure that your patient has an insurance that your practice accepts can help ensure that your claim for that visit will be reimbursed. But making sure that your patient’s insurance is going to cover the particular service you provided is the piece of the puzzle. In this quick tip, we show you how to prevent denied claims when the service you provided isn’t fully covered by the insurance plan your patient has.

Claims_management.pngDenied Claims Management: Uncovered Services

A list of covered services can be found in the written agreement between you and the insurance company. Not checking the guidelines of that agreement or eligibility for the service to be provided ahead of time can result in performing a service that is uncovered by the insurance, leading to a denied claim.  For example, for those practicing in Texas, a common mistake that practice's that accept Blue Cross Blue Shield (BCBS) make is not knowing that corneal topography is not covered by BCBS, even though it is a very common test that practices run frequently.

To easily prevent this kind of claim denial, review the payer guidelines for the treatment you are going to provide to see if it meets your patient’s health plan’s coverage criteria. To be fully sure about the services covered, you should use an automated real-time eligibility system usually provided by clearinghouses and practice management systems. 

Now, let’s talk about when you actually have to face a denial like this. You have two options on how to deal with it: bill the patient or write off the claim.

Billing the patient is an unpopular option because nobody likes an unexpected bill and it might mean losing your patient. It could also result in a bad online review that could tarnish your business's reputation. So before you bill your patient, think about whether it’s worth upsetting them. The other option is to simply write off the balance and make sure that it doesn’t happen again.

To prevent either from happening in the first place, it’s important to read your payer specific guidelines and pull eligibility benefits before the appointment so you can inform your patient of their financial responsibility if the service is not covered by their plan.

Need more tips to prevent claim denials? Download our eBook, Top 7 Reasons for Denied Claims.

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Topics: Insurance Claims

Want more optometry practice management tips? Check out our blogs.