Eligiblity, Payment, and Billing Procedures

Eligibility, Payment, and Billing Procedures

There are a couple of factors that can determine the eligibility of a patient, and one of these can be if their insurance premiums are paid on time. Many employers offer their employees’ health insurance, and the employers usually deduct their insurance premiums because it can help not to have a lapse in the employee’s insurance premiums. The plans in which are supported by the government such as Medicaid plans the income is the factor, and this is what decides the eligibility for the patient (Valerius, J., Bayes, N., Newby, C., & Blochowiak, A., 2014). The eligibility can change from month to month.

The patient will be notified in advance when a planned service is not covered with their insurance, and the patient is responsible for paying the bill. There are some payers that compel either the physician or the health care provider to use a specific form to tell the patient about the uncovered services. Financial agreement proves that the patient was told about their responsibility to pay before the services are offered and this form needs to be signed by the patient (Valerius, J., Bayes, N., Newby, C., & Blochowiak, A., 2014).

Example one: A medical specialist will call the patient to inform her that she is financially responsible for the visit on Wednesday because her insurance lapsed. The reason that the lapse was for non-payment and this will not cover the visit.

Example two: Mrs. Williams a patient called the OBGYN Clinic, so she can schedule an appointment to have a pap smear because she was spotting. Medical specialist from the clinic calls and explains that she can get a pap smear, but she will be countable for paying for the service. Medicaid will only cover two pap smears in 12 months, and this will be her third, even though this was preventive services.

References

Valerius, J., Bayes, N., Newby, C., & Blochowiak, A. (2014). Medical insurance: An integrated claims...