1 Deductible

Example

• A patient has a contracted deductible of $1,000. When the patient visits the doctor, the insurance company reviews the claim and allows $800 for the services performed. Since the deductible has not yet been met, the entire $800 is applied toward the deductible, meaning the insurance does not pay anything for this visit. The patient is responsible for paying the full $800. After this payment, the patient still has $200 remaining to meet the deductible

  After a few days, the patient visits the doctor again, and this time the insurance company allows $400 for the services. Since $800 has already been applied to the deductible, the remaining deductible balance is $200. Therefore, $200 of the allowed amount is applied toward the deductible, and the patient is responsible for paying that portion. The remaining $200 is covered by the insurance company, assuming there is no coinsurance. At this point, the patient’s $1,000 deductible is fully met, and future covered services will be paid according to the plan’s benefits.

• In simple terms, a deductible is the amount a patient must pay before the insurance company begins to cover any costs.

Actions

• First, we need to verify the status of the claim. This can be done by checking the status through the insurance web portal or by calling the payer, as we need the Explanation of Benefits (EOB) of the claim.

• If we call the payer and find that the claim has been processed entirely as deductible, we must collect key details, including the allowed amount, deductible amount, claim number, processed date, the name of the representative, and the call reference number. In addition, we must request a copy of the Explanation of Benefits (EOB) through the available method, whether by mail, fax, or email.

• If a claim is processed incorrectly as deductible, we must ensure that it is sent back for reprocessing and then follow up on the claim after the turnaround time (TAT) provided by the representative.

• After receiving the EOB, we will either post it ourselves or forward it to the person responsible for posting payments.

• Before billing the deductible amount to the patient, we must confirm whether there is any active secondary insurance. If a secondary policy exists, we verify the eligibility and then send the claim to the secondary payer.

• Sometimes, especially in the case of Medicare, the insurance will automatically crossover the claim to the secondary payer. In this scenario, we wait up to 30 days, and if no response is received from the secondary insurance, we then contact them and take the necessary action.

• If there is no secondary insurance, then we release the claim to the patient.