Page 32
CODING & BILLING
not a guarantee of payment," but that's just a carefully constructed canned statement. A verification of benefits isn't a guarantee of payment, but it is a guarantee of coverage and benefits. After all, the insurer knows best whether a patient is covered on the date benefits are verified. You can also use documented inaccurate information to support a breach-of-contract claim.
9 Insurance companies must provide adequate coverage and benefit information.
Before the ACA, insurance companies weren't required to provide certain coverage information unless specifically asked. Providers often learned after the fact that services were "non-covered," excluded or restricted by "limitations." Now, insurers must provide a specific, easy-to-understand benefit summary. The Summary Benefit Coverage (SBC) must clearly explain all referral requirements, benefit rates, deductibles, co-insurance, co-pays, out-of-pocket maximums and additional out-of-pocket responsibilities. Think of it this way: If it isn't clearly documented as a limitation or exclusion in the SBC, it should be covered.
10 Insurance companies cannot rescind policy coverage once a claim has been filed.
It's not uncommon for insurers to retroactively scrutinize applications for something — anything — they overlooked and can fabricate to their advantage, using it to justify termination of coverage and recoupment of benefits paid out. Along with leaving many people uninsured, the practice has hurt a large number of providers. Don't let them do it. The ACA prohibits insurance companies from rescinding benefits unless there's substantial evidence of fraud.
