To be a successful Front Desk Specialist or to effectively manage a medical private practice, you need to know the lingo. Today, we’re going to define the terms frequently used when verifying a patient’s insurance benefits.  

Provider Referral/Prescription: A written recommendation that a patient obtains from their Primary Care Physician (PCP) for the patient to seek treatment with a specialist, such as a physical therapist. 

Insurance Referral: An authorization or permission from your insurance plan for treatment with a specialist provider issued by a PCP. If an insurance referral is required but not obtained, the insurance plan may not pay for the services rendered.   

Authorization: An authorization, sometimes referred to as ‘preauthorization’ or ‘precertification’, is the approval from a patient’s health insurance for treatment by a specialist, deeming it medically necessary. Authorizations, if needed, should be obtained before treatment is rendered. If a request for authorization is denied, the provider and/or the patient have the right to submit an appeal. If services are rendered outside of the approved date range and/or go over the number of visits approved, services will be denied by the health insurance carrier.  

Patient Responsibility: The portion of a medical bill that the patient is required to pay in full. This figure can be determined when verifying the patient’s insurance benefits. Patients should sign a ‘financial responsibility statement’ to confirm they are aware of their responsibility and agree to pay that amount. 

Deductible: The amount the insured patient must pay for covered health services before the insurance plan starts to pay. It is important to verify how much a patient has paid towards their deductible to ensure you are not over-collecting, which would require a refund to the patient. 

Copay: A fixed amount that patients pay for a covered healthcare service once their deductible has been met. You can determine if a patient has a copay by reviewing their insurance card or verify when checking their insurance benefits. Copays are required until the patient’s out-of-pocket maximum is met. 

Co-insurance: The percentage of costs of a covered health care service you pay after you’ve met your deductible. For example, Medicare is an 80/20 plan which means 80% will be covered by Medicare while the remaining 20% is patient responsibility or secondary insurance. 

Collection Tip: A patient’s deductible will be what the insurance company allows for each visit. A patient's deductible will be what the insurance company normally allows per visit. Explain to your patient that if they pay a certain amount towards their deductible every visit then this will prevent a large bill from being sent to them later. 

Knowing these terms and how they impact your bottom line and patient experience are crucial to success in your practice. In need of administrative assistance? We offer a ton of resources such as customizable forms, front desk training, and virtual administrative services. Send an email to info@accountmattersma.com to learn more.