Eligibility, Payment, and Billing Procedres

There are many steps that are taken in order to make sure the eligibility of a patient is verified. The medical insurance specialist needs to make sure what the patient’s general eligibility benefits, the copayment (if any) that the patient needs to pay, and if what is being done to the patient is even covered under the rules of that insurance. A factor that determines patient general eligibility for benefits would be the patient pay the premium that is required on time. If it would have to do with Medicaid, then it would be checking the eligibility monthly if there is a change in employment or income.

When the insurance does not cover a planned service, then we must immediately let the patient be aware of the financial responsibility. The medical insurance specialist must discuss the situation with the patient and introduce the financial agreement form. This form is an agreement done by the patient as a proof that they were aware of the obligation and they need to pay before the services are given. Let’s just say that the reason the planned service is not covered is because the patient has not paid the premium on time. Since the patient did not comply with paying their premium on time, they have to deal with the consequences of either fixing that situation or having to sign the no covered services agreement. The following are examples of patient charges with corresponding billing transactions: Example 1

Service to be performed:Laparoscopic Cholecystectomy
Estimated Charge:$1,229.00
Date of Planned Service:July 7, 2013
Reason for Exclusion:Laparoscopic Cholecystectomy is not covered under insurance. I, Tracy Evans, a patient of Dr. Royce, understand the service described above is excluded from my health insurance. I am responsible for payment in full of the charges for this service.

Example 2
Service to be performed:Gastroscopy
Estimated Charge:$954.00
Date of Planned Service:August 20, 2013
Reason for Exclusion:Gastroscopy is not covered under insurance. I, Penelope Cruz, a patient of Dr. Royce, understand the service described above is excluded from my health insurance. I am responsible for payment in fill of the charges for this service.