I work for a physicians office and have encountered a problem with patients that present for services. Patients are presenting insurance cards at the time of service implying that they have coverage through the company. We file EDI and the claim has edits and one of these edits is insurance verification. These claims are rejected stating the termination date or not in effect on date of service. What leagl recourse do we have?

All of the physcians offices I know of, verify insurance at the time of the visit, in fact you don't go back till the office people call and verfiy your co-pay, deductables and so on.

So for future you check and verify insurance prior to service.

But of course the people say, I was sure I had covered, Idid not know I was cancelled, hard to prove fraud, so you bill them and turn it over to the collections people

It's kind of standard now a days for a doctor's visit for the office girls to check the status of any patient's health insurance sometimes even before the patient shows up for treatment or a visit. Nothing wrong with that. I had a dentist who had his office girls check on my dental insurance each time I visited him to be sure a procedure was covered - and that was while I was in the dental chair! I was not offended as they were just doing their job.

Most carriers have an online connection for service providers to immediately check whether coverage is valid.

You need to contact all the carriers you accept to see how you can verify coverage immediately.

Hi Missy,

I have worked in medical insurance for 10 years in just about every department. There are a few reasons this situation happens. There are millions of people out there that have no clue as to how insurance works and they do not even think about researching their plan. They assume that they hand over their card and that's the end of it.

Employers that offer health insurance do not educate their employees, insurance companies will not give a patient any information unless the patient/member/insured person asks the right questions.

In this scenario, having been the trainer and auditor for the financial recovery dept at a large insurance company I can agree that this is a problem.

Companies can change insurance carriers and the patient does not even bother to open the new information packet and continues to use their old card. Or in the lapse during a rollover to a new carrier the patient may not even be aware that the card they are using is no longer valid. Companies sometimes are slow to inform their employees to changes in their plans as well. There are also times when a company can retro term an employees coverage due to poor human resource/plan administrator personel, or a huge backlog of cases to handle.

The brunt of the responsibility falls on the Company. Although the patient should step up and keep themselves informed by asking questions and doing their research.

Coming for the insurance end, they also struggle with this. Companies delay in termination of coverage results in payment of a claim that should have been denied due to no coverage. I can't tell you the number of times this happens and as the carrier we also have no recourse except to attempt to recover the payment from the patient.

I agree that calling ahead to verify benefits and/or complete a preauthorization is the best route. But that is not foolproof either because as I stated previously there are plenty of times the insurance company has not yet received the termination from the employer/company and will quote benefits for the patient.

Just make sure to verify benefits as best as you can. And remember that a lot of patients are pretty much clueless. They need to take responsibility as well. They see an envelope from their insurance carrier and toss it aside like they would junk mail and then claim ignorance like you mentioned.

Sorry this was so long, and seeing as how it is 2:40 am I don't know if it even makes sense. Lol

Have a great one!
-M-