Rules of Verifying Patient Insurance

There are no published standard practices when it comes to verifying health insurance. Different states can issue different mandates for publically run institutions, but private institutions can operate on whatever policies they develop internally. With that being said, many hospitals have adopted similar standards when choosing what to do when verifying insurance, and there are a few things required of emergency rooms in particular.

Emergency Room Standard

• A standard of care is required of all emergency rooms in the United States. These are the rules put out by the national committee for certifying hospitals known as the Joint Commission of Hospital Standards. If your hospital runs an emergency department, you must accept all patients no matter what their ability to pay might be. If a patient comes in, you must treat him and stabilize his condition before you can discharge him, even if he has no insurance at all. You may check for insurance while the person is in your care and choose not to perform unneeded tests. Performing life saving procedures is all that's required.

Admission

• Patients will typically provide insurance information prior to admission to a hospital. The admitting department will look into the coverage so they can fully inform patients of their financial responsibilities. The hospital can ask for a deposit and set up a payment plan immediately for any amounts the patient will be responsible for. If the patient is unable to pay, and the situation is not considered life-threatening, the hospital can deny admission.

Surgeries

• For surgeries, hospitals typically seek pre-authorization from the patient's insurer to determine what will be covered and, under some policies, this is required for payment of a claim. While it is in the best interest of the hospital to ensure where payment is coming from, it is not the hospital's duty. They do so as a courtesy.

Patient Responsibility

• Patients should be aware of the requirements of their policies. If the policy requires referrals or pre-authorization, the patient, and not the hospital, will be liable for the costs if the claim is denied. Also, while an insurer may verify to the hospital that a certain service or procedure is covered under the policy, that does not mean it will be covered in full. Depending on the reason and circumstances, the patient may be liable for any remaining charges.

  Under certain plans patients will pay a greater portion of the cost for hospitals not included in the insurer's "network." It is not the responsibility of the admitting hospital to inform you that another hospital in the area might cost you less. While they might do so as a courtesy, it is the patient's responsibility, ultimately.