EPISODE SUMMARY
Ever felt like you were crushing a game of Monopoly or Catan, only to have one bad card flip the entire board? In the world of private practice, Eligibility and Benefits (E&B) often feels exactly like that. You think your revenue is secure, and then—BAM—a missed rule or a shift in patient benefits leaves you disoriented and losing ground.
In this episode of The Claim Game, Jeremy Zug dives deep into two "hidden" steps that often trip up even the best practices: updating accumulations and preventative patient communication. We’re moving beyond the one-time snapshot and looking at how to track the moving target of deductibles and out-of-pocket maximums. Whether you’re a solo provider or managing a large agency, mastering these domains is the only way to turn your billing system into a revenue engine rather than a drain on your mission.
KEYWORDS
Revenue Cycle Management, Eligibility and Benefits, Private Practice, Patient Communication, Medical Billing, Deductibles, Cash Flow
TAKEAWAYS
E&B is a Snapshot, Not a Guarantee: An eligibility check is only accurate for the 15-minute window in which you looked; it is a quote, not a promise of payment.
The Power of Accumulations: Patients rack up healthcare costs across multiple specialties throughout the year. If you aren't regularly updating their "accumulation" (how close they are to meeting their deductible), you risk overcharging them—which leads to messy refunds—or undercharging them, which makes collections nearly impossible once they leave the office.
To Be Clear is to Be Kind: Preventative communication is the bedrock of patient trust. Surprising a patient with a $4,000 bill on the day of their appointment is a "trust-degrader" that can lead to abandoned care and a damaged reputation.
Use the Right Tools: Don't reinvent the wheel. Using standardized E&B templates and benefit summary emails ensures your front office, clinicians, and patients are on the same page every single time.
Process Over Magic Bullets: As shown in our Pennsylvania agency case study, injecting repeatable SOPs and clear communication into a fragmented system reduces aging AR and increases both patient and clinician satisfaction.
CHAPTERS
00:00 Introduction: Zooming In on Eligibility
02:12 Why Eligibility Isn’t a One-Time Check
04:59 Understanding and Managing Patient Accumulations
08:45 Communicating Financial Responsibility to Patients
12:42 The Consequences of Not Communicating Costs Upfront
14:02 Using Templates to Fix Accumulations and Communication Gaps
16:05 Case Study: How One Practice Recovered from Eligibility Breakdown
17:43 Conclusion: How to Protect Trust and Revenue with Better Eligibility
RESOURCES
Today Sponsors: Blueprint
Learn More About The Claim Game: Visitpracticesol.com/podcast
The Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visitingThe Hourglass Learning Hub.
Our Blog: Explore years of educational articles on billing and practice management atPractice Solutions Blog.
Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.
Images: Benefit Stages, Benefit Summary Email Template, Eligibility & Benefit Check Template
