Check Point: Eligibility, Payment, and Billing Procedures

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Check Point: Eligibility, Payment, and Billing Procedures
Factors for Patient Eligibility
There are many different factors that determine eligibility for patient with employer-sponsored benefits. For example if an employee that works full-time changes to part time employment, the coverage may end or change drastically. Many facilities only provide coverage to employees that are employed full time.

Procedures for Non-coverage

There are appropriate steps to take when insurance does not cover a planned service. Insured patients’ policies require a facility to discuss with them when a service is not covered and of their responsibility for any accrued charges. Some payers require a physician to use a specific form when notifying a patient. For example, many physicians use what is called a financial agreement form before the services are given. In this case, the patient is informed of the financial obligation and must sign the form to prove that they have been informed before the services can be provided. The forms may contain information such as what type of service is to be performed, an estimated charge, the date that the service is planned, and the reasoning why it is not covered. The bottom of the form would have a statement that requires the patient to sign stating that they acknowledge and understand all of the above information.

Importance of Patient Knowledge

In my opinion it is extremely important for a patient to understand their obligation before receiving services because that patient has the right to refuse that responsibility along with the service. A patient should always be aware of the coverage and non-coverage of their insurance benefits. Most people are willing to pay for preventative services, as the service is a great idea.


If the financial obligations are not properly disclosed either to the patient or the provider; there can be legal action. For example, if a provider does not inform a patient that their...
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