Identifying payers by plan type – setting the right expectation or administrative nightmare?

Practice management systems have multiple methods for identifying and classifying insurance payers to assist in collecting and reporting data.  It may not be necessary to identify payers by plan type but it certainly makes the billing process more efficient – for staff and for patients.

Insurance companies may have different types of plans and/or different levels of benefits for the same plan.  A claim’s address may be the same for the various plans but it may be different.  More often than not, the payer number/identifier for electronic claims is the same no matter the type of plan which means everything goes to the same place regardless of the name we attach to it (e.g. Medicaid Pending, Medicaid Family Planning, Cigna-Medicare, etc).  Commercial products will have different levels of benefit and varying copays.  Do they also offer a Medicare Advantage or Medicaid managed care option?  When this is the case, classifying patients by plan type will assist staff in making better decisions.

There are a large volume of Medicare Advantage plans available to Medicare eligible beneficiaries.  They are available through payers whose names are very familiar – Cigna, United Health, BCBS and the list goes on.  Some of these plans follow Medicare guidelines, or more specifically, those Medicare guidelines that exist in the fee-for-service world.  For non-FQHC practices, routine services are generally not covered.  When scheduling, checking in and/or during check-out, identifying the type of plan affords an opportunity to adequately advise the patient BEFORE services are rendered while also collecting the proper cost-share at the time of the visit.

Identifying the plan is particularly important when it comes to Medicaid.  Patients may be eligible for Medicaid but benefits may exist only for certain services.  If enrolled in a plan with limitations (e.g. family planning), having a payer that indicates this benefit limitation affords a greater opportunity for staff to collect for services not related to family planning.  Many CHCs may offer services whereby patients are assisted in completing Medicaid enrollment applications based on qualifications.  When classified as “Pending”, the process of monitoring the enrollment of these members is greatly improved.  The patients and associated claims are easily identified for purposes of tracking, follow-up and confirmation of Medicaid eligibility.  In some states, the enrollment process can be lengthy and may be retro-active yet when all Medicaid beneficiaries are grouped into a single payer, management of the accounts receivable is further complicated given the varying reasons for claims to remain outstanding.  Each member and claim will require review to determine the reason for non-payment, to confirm the patient’s eligibility status, and to then take corrective action based on the results obtained.  However, when grouping patients based on plan type, a good biller will know what to look for within each group and what action is likely required before ever picking up the phone or logging into a secure website.

Confirming eligibility at the time of service is a critical component of the billing process.  Identifying the patient based on the level of benefit/plan type sets the right expectation before, during and at the end of the visit.  Patients can be advised, up front and with increased accuracy, whether or not their insurance will cover the visit and what their financial obligation will be.