Insurance
Insurance knowledge centers on who pays, how much, and under what rules. Learn the vocabulary: premium (cost of coverage), deductible (amount paid before benefits begin), copay (fixed amount per visit), coinsurance (percentage of cost after deductible), and out-of-pocket maximum (annual cap). Know the payer types: commercial, Medicare, Medicaid, TRICARE, and workers' compensation, and how each affects eligibility and billing.
Understand eligibility and benefits verification: confirm active coverage, effective date, plan type, network status, and whether the service needs prior authorization or a referral. Know coordination of benefits when a patient has two plans, and the concept of medical necessity as the payer's test for coverage. Also know the difference between in-network and out-of-network benefits and why a non-covered service may still be billed to the patient with proper notice.
Traps: assuming an active card means active coverage on the date of service; confusing a copay with coinsurance; forgetting that Medicare and Medicaid have different participation rules; and billing a patient for a service the payer has not yet denied.
Rule of thumb: verify eligibility before the visit, not after the denial. A denied claim is not automatically patient responsibility.
Worked example: a patient presents a card with a $1,500 deductible and 20% coinsurance. The office verifies the plan is active and in-network, collects the copay, and explains that the remaining balance depends on the deductible status.