Brace Health resources
Practical guidance authored by the people who work on billing and practice operations every day.
4 resources
Before relying on a TRICARE therapy cost estimate, confirm the patient’s plan and region, use current plan-specific cost information, and compare the estimate with the payer’s assigned responsibility. In one case, our daily comparisons revealed that an in-network practice was being estimated as out of network.
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A therapy practice can make a more defensible pre-visit estimate by combining the benefit information available, the planned service, and relevant claim history. Explain the assumptions and uncertainty; only the payer’s claim adjudication determines the final insurance result and patient responsibility.
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A benefits check can return information available from an eligibility transaction, such as coverage status or benefit details. It does not guarantee that a specific service will be covered or paid; claim adjudication depends on the submitted claim, plan terms, provider and service details, and payer rules.
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A practice should distinguish an estimate from the patient responsibility established after the claim is processed. Before requesting payment, reconcile the payer’s adjudication and any contractual adjustments, then communicate the balance and payment options clearly under the practice’s policies and applicable rules.
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