Patient Benefit Verification: 7 Easy, Essential Questions
Patient benefit verification means confirming, before a client’s first session, what the client’s plan covers and what the client owes. It takes one call or one portal check, and it prevents the surprise bill and the denied claim later. This post gives you seven questions to ask on every verification, and a note on when to repeat the check.
For a broader view, see our guide to insurance verification for therapists and the insurance verification and eligibility checks service.
Why patient benefit verification comes before the first session
A card in a client’s wallet does not prove coverage. Plans end, employers change and behavioral health benefits can sit under a different carrier. Verification tells you three things: the plan is active, mental health care is covered, and what the client pays. Document the date, the name of the person you spoke with and the reference number. That record helps if a payer later disputes what it said.
Question 1 to 3: Is the plan active, and who pays for mental health?
Ask whether coverage is active on the date of the first visit. Then ask who manages the behavioral health benefit. Some plans carve it out to a separate company, and that company becomes your claim address. Third, ask whether you are in or out of network. The answer changes everything that follows. Our guide to out-of-network billing for therapists explains that path.
Question 4 to 5: What is the deductible, and what is left of it?
Ask for the deductible and how much the client has met so far. The deductible (HealthCare.gov glossary) is the amount a client pays for covered care before the plan begins to pay. Then ask for the copay or coinsurance that applies after it. Say the numbers back to the client so they know what to expect. Patient benefit verification is also where you learn the plan’s allowed amount, which is the most the plan pays for a covered service (see the HealthCare.gov definition).
Question 6 to 7: Are there visit limits, authorizations or telehealth rules?
Ask whether the plan limits the number of visits, and whether it requires prior authorization for therapy or for any add-on service. Ask whether telehealth is covered and which place-of-service code to use. Rules differ by plan, so write down the answers for each client instead of assuming. If the client has a second plan, ask about it now. Our secondary claims service handles the second claim.
When to repeat patient benefit verification
Many plans reset deductibles at the start of a new plan year. For many that is January, but some plans use another date, so check each one. Re-verify your active clients when the plan year turns, and any time a client changes jobs or insurance. Add it to your monthly billing checklist so it does not depend on memory.
Get time back by adding an insurance expert
Verification is the first task solo therapists drop when the week gets busy. A billing service with an insurance expert on the phone does it for you, records each answer and flags problems before the visit. Read what a billing service does each month and compare it with a part-time biller. If a claim does deny, see who follows up on denied claims.
Frequently asked questions
What is patient benefit verification?
It is the check you make before a first visit to confirm the plan is active, what mental health benefits it covers, and what the client owes.
How long does patient benefit verification take?
It varies by payer. A portal check can be quick, and a phone call can take longer. Plan for it before the appointment, not on the day.
Should I verify benefits for every client?
Yes. Verify each new client, and re-verify active clients when the plan year resets or their coverage changes.
Can a billing service verify benefits for me?
Yes. MCM South runs insurance verification and eligibility checks for psychotherapists and psychiatrists and documents each answer.
Where MCM South works
MCM South Medical Billing Service, LLC works with psychotherapists and psychiatrists in our ten currently served states: Georgia, Massachusetts, Connecticut, Texas, Florida, New York, Colorado, Tennessee, North Carolina and Illinois. We serve solo and medium-size practices that bill mental and behavioral health. Founder Michael Williams has worked with insurance payers in all 50 states. Browse the state and regional billing guides for rules that vary by state, or see our billing services.
This post is operational guidance for billing, not legal advice. Rules change, so confirm with the payer or your counsel.
