Insurance and Authorizations

Practices must know which insurance plans they have contracts with and those they do not, those that require special authorization, and what insurance information is required at time of scheduling. If insurance is not verified at time of scheduling, it may result in delayed service or billing.

Best Practices During Scheduling

When scheduling an appointment, the scheduler should:

• Verify insurance coverage.
  • Check the Payer Information SharePoint site for clarification on which insurances MGH/MGPO contract with. For reference, schedulers may bookmark this site; it is also accessible under Partners Utilities in the Start menu on any Mass General Brigham computer.
  • Transfer caller to Patient Service Center (PSC) if coverage needs updating.
  • If MGH/MGPO does not contract with the patient’s insurance plan:
    • For new patients: Do not schedule an appointment. Refer them to their insurer to find care within their network. (See Tools and References for a sample script.)
    • For existing patients: Refer patient to Patient Financial Services (PFS) to review options, including making self-pay arrangements.

• Verify the guarantor.
  • If you cannot verify the guarantor, if it is incorrect, or if it needs updating, warm transfer the patient/caller to the PSC. The PSC will update the information.

• Pay attention to insurance warnings in Epic (e.g., non-contracted and special messaging).
  • Refer to the Plan Participation Grid on the Payer Information SharePoint.

• Pay attention to which patients require special authorization (e.g., MGPO ambulatory care, primary care/specialty).
  • Confirm benefits coverage in Epic.

• Run eligibility check and resolve issues.
  • Determine if referral or authorization is required.
    • Obtain prior authorization/pre-certification from payor.
    • Obtain a referral. Complete referral record in Epic. Confirm medical necessity/billing code requirements.

• Verify and communicate the patient’s responsibility for co-payments and co-insurance in Epic.
  • Verify the patient’s eligibility in the New England Healthcare Exchange Network (NEHEN).
  • Identify alternate funding/special billing if necessary. For example:
    • Research
    • Motor vehicle accident (MVA)
    • Workers’ compensation (WC)
    • Third party liability (TPL)
    • Do not bill (DNB)
    • Grants
    • Cosmetic flags

Other Best Practices

• Follow up with patients at least one week before their appointments if referrals and authorizations are not secured.

• Designate a practice representative to attend the monthly Payer Communication Forum for updates on various aspects of contracting.

• Use a practice-/department-based payer communications email and distribution list to communicate insurance updates to employees in the practice.