What Questions Should You Ask a Payer When You Call to Verify a Patient’s Physical Therapy Benefits

Calling to verify benefits is time consuming. Below are the steps involved when calling an insurance company. These vary depending on the payer and their process.

1.) IVR

• Usually there is an automated system which requires you to make multiple selections and enter information about the patient before transforming to a live agent. 
• Typically you will be asked what the call is regarding and you will have an option for benefits and eligibility 
• You will be asked to enter the patient’s subscriber ID
• Some of the insurances, for example Aetna, will provide you with the benefits through this system and there will be no live agent to talk to. Once you enter the information requested about the patient, it will ask you your NPI and which service type you want benefits for. It will then rattle off a lot of information regarding the patient responsibility

2.) Wait on hold for a live agent
3.) Speak with a live agent

• The live agent usually has a script they follow. They ask you a few questions about the patient and about your clinic, then tell you a bunch of benefits related information

4.) Ask any additional questions you have that the live agent didnt already cover 
5.) Confirm everything that the live agent told you so you make sure you understood the information correctly
6.) Get a call reference number

• All live agents will have an ID or name and a call reference number to give you. The reference number will be important to save in case there are billing issues down the road and you need to file an appeal.

The following questions should be asked and answered when calling a payer:

• What is the effective date for this policy?
• What is the policy type?
• Does the plan run on a calendar year basis or plan year?
• What is the deductible – including how much has been met for this year
  • Get individual and family level benefit if applicable
• What is the Out of Pocket Maximum – including  how much has been met
  • Get the individual and family level benefit if applicable
• What is the coverage for the benefits you want?
  • Is your service covered 100% or is there a co-insurance?
  • Is there a copay?
• Is there a visit limit for the service and are other benefits part of this limit?
  • If yes, how many have been used
• Is authorization required?
  • If yes, how is it after the first visit or after a certain number of visits
  • How is authorization obtained?
• What is the reference number for this phone call?

If at any time you are unsure of something the representative has said or need to review something do not hesitate to ask the representative to review. Sometimes you even might want to get transferred to a manager or another rep if some of the information the rep gives you seems inaccurate.

If you need help verifying your patients’ benefits, One Body can help! Clinics just like yours outsource verification of benefits to us so they don’t have to wait on hold or deal with interpreting the information given by payers. One Body does that for you. We provide you with a comprehensive, easy to understand benefits report so you know everything about the patient’s responsibility and the payer’s reimbursement requirements before seeing the patient. Fill out the contact form below or email us at hello@onebodywellness.com for more information!