WS How Insurance Works General Information


General Insurance Information:

Most clients do not understand the complexity of their insurance benefits and the insurance billing process. We understand that insurance is confusing and can be overwhelming. We hope that these resources are helpful and provide some comfort and peace of mind making decisions about your care. 

The Insurance Billing & Claims Process:

1. The first step in the insurance process begins when a client provides WS with his or her insurance information, demographic information, guarantor information, and subscriber information. It is imperative that all of this information is provided in a timely manner and is completely accurate. WS also has to have permission from the client to use this information to check insurance benefits and submit claims. (This is why we cannot simply provide clients with insurance benefits when they inquire about an appointment. There is extensive information and permission required so that we can check your benefits.)

2. WS will take the information provided, contact the insurance company, and check the client’s eligibility and benefits.

3. It is important to understand that all insurance companies state the following disclaimer when conducting an eligibility and benefits check, “A quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service.” This disclaimer means that insurance companies will provide a quote of insurance benefits that may or may not be accurate and up-to-date. We find that approximately 60% of initial benefits checks contain inaccuracies. To try and circumvent this common problem WS checks eligibility and benefits using multiple sources to try and validate the information we receive. We find that adding redundancy to our processes helps to reduce the problems of inaccurate insurance benefits checks by approximately 20%. We advise our clients to consider all eligibility and benefits checks as a soft quote of benefits until the first three dates of service complete the insurance remuneration cycle.

4. When a client receives clinical services the client’s credit card on file is charged based on the eligibility and benefits check WS received from his or her insurance. WS will electronically submit an insurance claim to the client’s insurance company.

5. The insurance company will process the claim. This claim will either be rejected, denied, or accepted. If the claim is rejected then WS will follow-up, edit the claim, and resubmit the claim. The most common reason a claim is rejected is because the client provided incorrect information to the provider. If the claim is denied then WS will follow-up, edit the claim, and resubmit the claim. WS receives very few claims denials. The most common claims denial reason is because the client no longer has insurance and his or her insurance terminated. If the claim is accepted then the insurance company will process the claim based on the client’s benefits as per the policy provisions in the contract.

6. The insurance company will send electronic remittance advice (ERA) to WS regarding how the claim has been processed and what the payment provisions of the policy are as per the insurance contract. Clients receive an explanation of benefits (EOB) that contains the same information that WS received via ERA. Clients may receive an EOB via mail, email, or through their insurance provider portal.

7. If the insurance benefits on the policy include payment from the insurance company then WS will receive the payment. If the insurance benefits on the policy do not include payment from the insurance company then the ERA and EOB will show the total balance for charges as patient responsibility. For example, if a client has a deductible on his or her policy and the deductible has not been met then the insurance will not pay and the patient responsibility is for the balance on the account. Once the claim has been processed and WS receives the ERA and payment, if applicable, then the claim has completed the remuneration cycle.