Verification of benefits (VOB) explanation

This article will provide an overview of how to interpret the verification form and outline the next steps to take once you have gained a clearer understanding of the patients' policy.

A Verification of Benefits (VOB) form is a document that will confirm the details of a person's insurance coverage before receiving medical services or treatment. The purpose of a VOB is to ensure that the healthcare provider and the patient have a clear understanding of the insurance benefits and the potential out-of-pocket costs before any treatment is given. It helps avoid surprises in billing and can help the healthcare provider determine whether pre-authorization or additional paperwork is required. Reading a Verification of Benefits (VOB) form can seem confusing at first, but once you know what to look for, it becomes much easier to understand.

Brief synopsis of how medical insurance works: The member will have to meet their yearly deducible first. Once that deductible is met, the co-insurance then kicks in. The member will continue to pay that co-insurance until their out-of-pocket max is met. Once their out-of-pocket max is met, insurance will usually pay at 100%. Note: If a patient has no individual deductible, the family deductible will then apply.

 Here’s a step-by-step guide to help you read and understand a medical VOB:

1. Plan Details

In this section, you’ll find an overview of your health plan:

• Plan Type: This refers to the kind of health insurance plan you have. Common types include:
  
  • PPO (Preferred Provider Organization): Allows flexibility in choosing providers, both in and out of network.
  • HMO (Health Maintenance Organization): Requires you to use network providers and get referrals from a primary care physician (PCP) for specialists. Most HMO policies allow for gap exceptions, meaning you will be able to render services as an out of network provider if that gap is obtained.
  • EPO (Exclusive Provider Organization): Similar to PPO but with no coverage for out-of-network providers except in emergencies. Please utilize the gap exception if available. 
  • POS (Point of Service): Combines features of both Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans. 
  • OAP plan (Open Access Plan): Has the flexibility of a PPO (with access to out-of-network providers) and the convenience of no referrals for specialists. 
• Which insurance the member has: Ex. Blue Cross Blue Shield, United Healthcare, Medicare etc.. 
• Insured person: For instance, if the member is a dependent on the policy. 

2. Coverage Information

This is the section where you’ll see exactly what is covered under your health plan, and for which services. It will include:

• A general idea of whether the members deductible applies to those procedure codes
• If a pre-authorization is required or not
• If a PCP referral is required
• The specific services covered by your plan (e.g., doctor visits, lab tests, imaging like CT's, surgeries)

3. Co-pays, Deductibles, and Coinsurance

These terms refer to the amounts a member may need to pay out of pocket for services. Understanding them is crucial:

• Co-payment (Co-pay): This is the fixed amount you pay for a service at the time of care. For example, you may have a $25 co-pay for a doctor’s visit or $50 for a specialist.

• Deductible: The amount you must pay before your insurance begins to pay for services. For example, if your deductible is $1,000, you need to pay the first $1,000 of your medical expenses in a plan year. Once you’ve met the deductible, the insurance pays a larger portion of your costs (This is when the co-insurance kicks in).

• Coinsurance: This is the percentage of the cost you pay after meeting your deductible. For example, if the coinsurance is 80/20, insurance will cover 80% of the allowed amount and the member will then be responsible for that 20%.

See example below:

Tip: Hovering your mouse over the information icon on the right-hand side will display the definition for the selected section.

The final part of the verification form is where we summarize any additional requirements or restrictions. In this section we will let you know if a PDAC appliance is required (if you are billing for sleep), as well as pre-authorization and gap exception requirements. 

Once you have a clear understanding of the member's policy, you may proceed with creating any necessary pre-authorization or gap exception tickets, if applicable.