When you decide to take a new client, there is nothing worse than realizing after you see them that they aren’t covered by their insurance.  Many people don’t actually know what their insurance covers until they are denied for something. Learn about verification of benefits, why it is important to verify before you see a new client and how to verify benefits.

Some insurances don’t cover the whole cost of sessions. The client can have a co-pay or high deductible. Or a client can have medical coverage but limited mental health benefits.

If a session is not covered, the client is still responsible for the bill. But it can be hard to get them to pay after the service is rendered. People tend to start thinking a service isn’t worth as much after they realize they have to pay. You can take them to collections but it often isn’t worth the hassle for a session or two. And you should always know by then if they are covered. But you can avoid all that hassle, if you know what coverage they have before you ever see them.

Avoid the hassle of billing clients, taking them to collections or just not getting paid by verifying benefits before you ever see a client.

Don’t assume that because you are credentialed with their insurance, the client will be covered. Insurances have different products and you can be covered by some but not all their products. A client can have a deductible that needs to be met or a co-pay for each session. Sometimes mental health benefits are different from medical health benefits. A client may think they only have to pay a normal doctor co-pay but it may be different for their mental health benefits. Clients often aren’t aware of this information. You need to know this information before you see them. Simply verifying benefits can save you and the client some hassle.

How to Verify Benefits

There are two ways to verify benefits: calling the insurance or electronic (online) verification. Either way, you need certain information to verify benefits. You need to get this information from the client when you first talk to them before you make them an appointment. You can do this with a phone intake. You can download a  template for a phone intake from the Private Practice Forms page if you have Full Website Access.

Information You May Need

I think it is better to have too much information than not enough so the phone intake form I have created requests additional information from what is listed below. You can also use some of this information for your intake packet. Different insurances can ask for different information to verify benefits but for the most part, you will need the following information.

Client Information:

  • Full name
  • Date of birth
  • Insurance ID number
  • Insurance group number (if they have one)
  • Address
  • Phone number
  • Social Security Number (can be needed if you don’t have their insurance card numbers)

Provider Information:

  • NPI
  • EIN (or social security number)
  • Phone number
  • Office address

Calling for Verification of Benefits

You can directly call each insurance to verify benefits for each new client. Every insurance card has a number on the back to contact the insurance. Sometimes there will be a number specifically for verification of mental health benefits. It may say “provider number,” “call for pre-certification,” “call for authorization” or something similar. You can call this number to verify benefits. Have the information above ready or a completed phone intake form when you call.

I don’t recommend calling to verify benefits each time you get a new client. It can be time-consuming to make these calls. You will have to write everything down instead of getting a print out of their benefits. And the call center may only be open during regular business hours. Often, you will be seeing clients during regular business hours and may want to call in the early morning, evenings or weekends when the call center may be closed. The biggest problem with calling is they can only tell you if the client is covered for the date or time period you ask about. You may have to call again to verify benefits periodically to check if there have been any changes. For all these reasons, I recommend using the online method.

However if you decide to call, you will tell them you are a provider (or out of network) and are calling to verify a member’s benefits. It is important to tell them if you are in network or not because it will affect the information they give you. It is a good idea to note who you speak with and the date and time of the call. They may give you a reference or certification number and you should note this as well. That way if you have to call back or have a problem, you can give them the number so they can find information about the earlier call.

You will need to get the following information:

  • Do they have a deductible? How much is the deductible? How much of the deductible has been met? Is it by calendar year or effective date?
  • What is the effective date for the plan?
  • Do they have a co-pay? How much is the co-pay?
  • Do they need pre-authorization? If so, how is this done?
  • Do they need a referral?
  • Are there limitations for diagnosis, type of therapy or CPT code? Is there anything not covered? Or anything that needs prior authorization?
  • Do they have a limit on number of sessions or need authorization after a number of sessions?
  • Is there a dollar limit on how much the plan covers?
  • If you are unsure, ask: Are you in network for their plan?
  • If you have never sent billing to that insurance before, you can also ask: Where do you submit billing (paper or online)? And what forms do you need?

Don’t Be Afraid to Ask

Remember, employees of the insurance company are being paid to answer your questions.

If you are ever unsure about anything related to billing, don’t be afraid to call the insurance company and ask. I know that some of the people you reach can be rude. It all depends on the person you talk to. Some are nice; some aren’t. Just remember, the person you reach is being paid to answer your questions.

Online Verification of Benefits

Verification of benefits can be much easier when done online or electronically than by calling. If you aren’t very tech savvy, don’t worry. You can contact the provider representative for the insurance you are credentialed with and ask them to train you to do online billing.

Online billing may be done through a secure website for the insurance. You will need an ID or username and password. The insurance will provide this or tell you how to get it. Some insurances work with a shared billing program that you may be able to use for all the insurance panels you are credentialed with who are a part of the program.

Once you are in the program and have your credentialed insurance companies connected to it, you can verify benefits and use it to bill for services. Most are simple to use and you can be trained you to use it. It may even have videos online to show you how to use the program.

Every program is different but you usually just choose the insurance, click on verify benefits and enter the client’s information. You can often search by client name and date of birth or insurance ID number. Once you find the client in the system, you can check their benefits and bill for them. When you check benefits online, you get all the information that you would normally get from calling and more. Plus, you are able to print it out to keep in the client’s chart. Since it is so simple, you can periodically check their benefits.

If you have an EMR (Electronic Medical Record) with billing capabilities, this may be a simple task that is a part of your practice management service. You can be trained to use the program to verify benefits from whoever you get the EMR service. Or they may have online documentation that explains how to use the service.

Important Note

Verifying benefits can help you know whether a client is covered and for how much. However, you have to realize it does not guarantee you will be paid. Insurances will even tell you this. I recently went to the dentist and used dental insurance. After I met with the dentist, the office manager gave me a printout of what was covered by insurance and what I would have to pay. It had a disclaimer saying it was not a guarantee that it would be my actual coverage for the services. They include the disclaimer because an insurance company can still deny a claim or benefits can change by the date of service.

You have to be aware that you can still be denied even if you take every precaution. But it does limit the chances that it will be denied. The client can end up owing more than the verification says too. This is why you need to explain this to the client at intake and in your informed consent. Your informed consent should make it clear that they are responsible for knowing their insurance benefits and what they are required to pay.[/fusion_text]