Patient Eligibility

Eligibility, Payment, and Billing

To receive payment for medical services rendered, establishment of financial responsibility must be conducted. A factor that would determine if a patient was eligible for insurance benefits, would be to ensure that all the individual’s premiums were paid. There are many companies which offer health insurance benefits to their employees that deduct the premiums automatically from the employees pay in order to avoid lapses in insurance premiums. For government-sponsored health plans such as Medicare, the eligibility factor depends on income and can change monthly. (Valerius, Bayes, Newby, & Blochowiak, 2014)

When insurance benefits do not cover a planned service, the appropriate step would be to notify the patient in order to prepare them for the financial responsibility before the service is performed. In most cases, this requires that the medical practice use specific forms filled out by the patient in order to verify the patient awareness of the non-covered services. These forms acquire acknowledgement that he or she understands the obligation to pay before the service can be provided. (Valerius, Bayes, Newby, & Blochowiak, 2014)

An example of eligibility would be if a medical specialist such as an urologist might notify a patient of their financial responsibility because he or she’s scheduled appointment would not be covered by insurance due to non-payment of premiums, therefore causing them to expire.

Another example of the eligibility factor would be if Mrs. Smith was schedule for an angioplasty procedure and the specialist informed her of the services that would be and would not be covered by Medicare. However, Medicare must contact the patient as well to inform her that the entire procedure, as well as pre-op and post-op would be covered, but she would have to cover the cost of the stents because the supplier did not participate in insurance plan.

Reference

Valerius, J. D., Bayes, N. L., Newby, C., &...