Most insurance companies have a website that enables a patient and or provider to log in, in order to keep track of visits to the doctor and subsequent payments or in the instance of a providers office, the on-line aspect is used to obtain eligibility and other requests that a patient may need depending on the type of plan they have. These already high priced commercial insurers do not charge a fee to have someone who is already underpaid and underemployed to check to see if a new patient is truly legitimate or if the physician is going to be doing charity work. Now that EMR systems are becoming the one stop shop for patient medical record access, they also have integrated the capability of verification and eligibility into their software. However, none of this is free. So the eligibility or verification portion for EMR software is doing what the federal government does by charging a provider for on-line use in order to see if a patient is actually insured so that the physician can be reimbursed.
Some of these companies that offer eligibility access charge $25 a month or $25 for every 100 eligibility inquiries (25 cents per inquiry)that are made through their system. Since Medicare alone may have had some difficulty in handling the amount of work it would take to have a national database, they outsourced the work to other companies who also included billing as part of the package. This means that in order to stay in business these companies must charge because they need to pay staff to do the work. This is understood, especially when collecting the deductible money. Because there are some patients who pay per visit or will wait for a bill in order to determine what is owed, if they do not have a secondary insurance in addition to Medicare. This takes a lot of time and effort to process claims and to then determine what a patient must pay afterwards since Medicare only covers 80%.
The real issue here is being able to access eligibility for free. I say this because when you are only checking eligibility there is no money involved. In that, the physicians office is just checking to see if a patient is eligible to be see at the time of visit and what the co-pay or deductible may be and not how much a patient may owe for any visit new or old. Since that process does not involve collecting money as a biller would do in processing claims, verification or the verifying of insurance should be free of charge. Medicare does not have a user-friendly card access so that medical office staff can contact the number on the back of the card to inquire about patient eligibility. Medicare answers questions and conducts transaction information that is related to claims and dates of a particular office visit or procedure and the amount of each visit or check that they issue to a provider. Medicare does not provide anyother information in user-friendly format about the patient such as their prescription plan, or if Medicare is the primary or secondary insurance for the patient. These types of inquiry based questions should not have a fee associated with them because a claim is not being processed by simply verifying information.
If commercial insurers do not charge providers for on-line or phone use for the basics of inquiry, then Medicare should also have a streamlined process that does not charge a fee when it comes to eligibility for hospital or medical services, and to inform the provider if Medicare is primary or secondary. Prescription drug plan information and deductible amounts should also be included.
Why is this so crucial?
Because of the enormous delay in check processing and claims that are rejected because necessity and other codes were not provided when a claim was submitted or were requested afterwards in review of the claim. The office staff can only do so much. To fetch every penny would make most of our jobs as medical office staff similar to preparing taxes every single week. That's a lot of work for $15 an hour and no overtime. Don't you agree? However, the office staff in addition to their other duties can check eligibility and other prerequisites to ensure that a provider can be reimbursed for their services, but they need to be able to access this information free of charge because small offices do not generate the money that much larger facilities do so those costs need to be considered, since eligibility for each patient must be checked for each and every visit. A lot of this work is time consuming.
Besides, how would you like it if your bank, credit card company, investment company began to charge you, even if you were just checking your balance? Once this occurs it would be time consuming to try and find an institution that does not charge a fee.