First Key: Collect and Verify Patient Information

Unless a patient visits the healthcare facility on a regular basis (e.g., weekly allergy shots or blood pressure checks), the health insurance professional should verify the patient’s information each time he or she visits the office. New patients must complete a patient information form on the first visit. Established patients should be required to update the form at least annually because within a year’s time the patient could have remarried, moved to a new address, changed jobs, or, most important to the health insurance professional, changed insurance companies. In addition to demographic data (e.g., name, address, age, gender), the patient information form should include basic items such as the insurance carrier’s name, policy and group numbers (if applicable), the insured’s name (if different from the patient), effective date of coverage, and any secondary insurance information. Some practices with a high volume of Medicare patients have a separate information form for Medicare patients.

After the patient information form is completed, the health insurance professional should check it over to ensure that the correct information has been entered in the required blanks and all information is legible. One key to successful claims submission is to have the patient provide as much information as possible, and the health insurance professional should verify this information.

In some situations, more than one insurer is involved. Such cases might occur when the patient and his or her spouse are covered under separate employer group plans or when the parents of a minor patient are divorced, and each parent has his or her own insurance policy. In the case of the latter, if the primary carrier is not designated on the information form, the health insurance professional should obtain this information from the parent who accompanies the child to the office.

In addition to the standard demographic and insurance questions asked on the patient information form, many healthcare practices include a section (often at the bottom of the form) for the patient to sign a release of information and an assignment of benefits. Other practices use separate forms for these functions. Although HIPAA law says it is unnecessary for treatment, payment, or (healthcare) operations (TPO), most healthcare facilities request that patients sign and date a valid release of information before they submit an insurance claim. Most facilities also require that patients sign an assignment of benefits, authorizing the insurance carrier to send payment directly to the healthcare provider.

Verifying a patient’s current insurance coverage (e.g., enrollment and copays) is one of the most important administrative duties of the health insurance professional. Accurate verification has a direct impact on the promptness and correctness of claim payments. Many third-party payment delays are caused by inaccurate verification on the part of the practitioner’s office or missed information at the time of the verification. Many insurance companies offer online services for providers to exchange eligibility and benefits information on their patients electronically. After obtaining a complete and accurate patient information form, the health insurance professional should make a photocopy of the patient’s insurance identification (ID) card and place it in an easily accessible location in the patient’s health record, such as inside the front cover. Many insurance ID cards also have information on the back. The health insurance professional should always check the back of the card for information and make a photocopy of it as well.