How to Verify Coverage to Make Sure You Get Paid

Kathy Flynn
Apr 12, 2018 10:48:03 AM

I recently listened to a webinar that reminded me of something I already knew: getting paid for services provided to patients is not guaranteed. Most phone calls made to payers verifying coverage and benefits will start with a disclaimer to that effect. 

Here are a few statistics that demonstrate the importance of that phone call:
  • Up to 20% of claims will be delayed or denied
  • On average, it cost $25 to rework a denied claim
  • Up to 90% of denials can be prevented
  • Up to 75% of denials are for ineligibility
  • Up to 20% of total charges will be denied
  • Up to 5% will be written off

Source: ZirMed. (2018, April). Stop the Write-Offs: 7 Strategies to Drive Cash Flow.

The bottom line is that the coverage and benefits phone call is more important than ever!

Pediatric Therapy EMR

The coverage and benefits phone call is more than verifying the dates of coverage and co-pay/deductible amounts. These days, many coverages are diagnosis driven; the service is covered, but the diagnosis is not. Often, pre-certification or an authorization is required and the payer might not disclose that information if you do not ask. As a provider, practicing ‘due diligence’ prior to treating patients will help your cash flow and bottom line.

Fusion has created a coverage and benefits questionnaire to help you get the information needed to submit the cleanest claims possible. This won't guarantee payment, but it will improve your odds of getting timely payments.

By addressing these questions, you can reduce the time and money that denied claims cost your practice.

(Many of the fields on the questionnaire can be recorded in the Patient Information Payer section of Fusion Web Clinic. There is also an option to upload the form into Patient Information.)

No one likes calling payers, but would you rather:

1. Call to get the best information I can before submitting a claim?


2. Call and fight for the payment after the claim is denied?

The questions are below. And you can download a printable version below.

Coverage & Benefits Verification Questionnaire

Disclaimer: This questionnaire won't guarantee payment, but it may improve your odds of receiving timely payments.

Information to Have Prior to the Call

  • Patient
  • Date of Birth
  • Payer
  • Subscriber ID
  • Payer Phone Number
  • Are you in-network with this payer?
  • Planned Billing Codes
  • Medical Diagnos(es)
  • Treatment Diagnos(es)
Basic Verification Information
  • Coverage Dates
  • Copay Standard:
  • Specialist
  • Co-Insurance Annual
  • Remaining
  • Deductible Annual
  • Remaining

Additional Verification Information

This information will not generally be included in your standard verification call. You will have to specifically ask about these items.

  • Yearly Visits for Therapy Allowed
  • Yearly Visits for Therapy Remaining
  • Is there a separate count for each service type?
  • Is ST/OT/PT covered?
  • Are the billing code(s) covered when billed with the diagnosis code(s)?
  • Is a referral from the primary care physician required?
  • Is pre-certification required?
  • Is re-certification required?
  • Is an authorization required?

Information to Gather at the End of the Call

  • Representative’s Name
  • Reference #
  • Date & Time

In-House Billing Kit

We've put together some resources to help you bring billing in-house. This In-House Billing Kit includes:

  • A Verification Questionnaire to use when calling payers to verify coverage
  • A 50% off coupon for our billing course, The Essentials of Insurance Billing for Therapy
  • A Billing & Collections Checklist to guide you as you interact with caregivers
  • A Payment Policy Generator to help you set expectations for caregivers
  • 7 Tips to Help with Billing & Collections handout
In-House Billing Kit

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