Many medical professionals and facilities experience claim denials, but in reality, the process is often misunderstood. In most cases, claim denials result from failing to verify benefits properly before providing services. Verifying insurance eligibility and obtaining prior authorization is an essential step in the medical billing process. Any practitioner or medical professional providing a service or medication must be willing to follow this process to avoid rejection.
As per records published on January 1, 2013, HIPAA-covered entities must comply with federally mandated operating rules for eligibility for a health plan. Therefore, as an independent operating clinic or hospital, you can check for your patient’s insurance eligibility. Patients’ eligibility is verified as the first step in the insurance claim process on a variety of criteria, including (but not limited to) coverage, benefit options, prior authorization, and pre-existing conditions. Due to its complexity, the process can be prone to errors and eventually affect the bottom line negatively. Before we further delve into the topic, it is important to know why insurance eligibility verification is done for every patient. As the first step of revenue cycle management, failure to verify the insurance eligibility can factor in the following side effects:
- As a provider, you provide care to patients whose insurance policies are inactive.
- If you fail to secure authorizations before providing services, it can result in claim denials.
- Patient financial responsibility is often unclear, resulting in delinquent accounts being sent to collections.
- When you cannot explain coverage to your patients, they may seek care elsewhere.
On that note, let’s look at some ways in this blog that we can incorporate on a daily basis to mitigate these problems and ensure smooth insurance eligibility verification.
- Prepare a checklist for the verification.
Prior to the patient’s visit, the front office must be equipped to collect the following details:
- Insurance name, contact number, and the address
- Insurance ID and group number
- Name of insured (in most cases, it might not always be the patient)
- The insured’s relationship with the patient
- Policy implementation and end dates
- Ready to fetch a physical copy of the card
- Status of the coverage – active or not
- Is the procedure, diagnosis, or services to be provided covered by insurance?
- Is your practice a part of the plan, in-network or out-of-network?
- Policy limitations, such as exclusions or documentation requirements for bills
- Is a referral, pre-authorization, or certificate of medical necessity required for payment?
- The patient’s co-pay and deductible amount
A PMS software connected to the clearing house can check for the IEV details electronically and verify them automatically in real-time, batch, or both.
- Contact the patient’s insurance company.
If you have the patient’s information, you should contact the patient’s insurer, regardless of whether you have worked with them before or not. If you reach out early on, you can get the verification request acknowledged and handled within a few days since insurers cover so many people. Most of these problems can be avoided if you already have a PMS software in place. But, if you are not equipped with one, you will have to go through this manual process and extract all the relevant data that you require. Dialling them and waiting for an agent to respond can sometimes take a long time. But remember that it is vital to ensure your current phone conversation is HIPAA-compliant before proceeding with the phone call. Also, in the event that you forget to ask for details during that time, you’ll have to repeat the entire process. In most scenarios, these things are unavoidable. But, if you can access the insurer’s online portal, you can gather most of the information you need before accepting the patient. In this regard, expEDIum can verify insurance details both seamlessly and in real-time, thereby enhancing the efficiency of the staff.
- Prior to every patient encounter, begin at the top.
The complete insurance verification process can be summarized in the two steps above. However, it is theoretically possible for patients to lose their health insurance or switch plans at any time. Therefore, you should collect the patient’s insurance details before every appointment or encourage them to do so via your practice’s patient portal. Also, it does not hurt to get a physical copy of their insurance every time they visit. No matter how long it has been since you last saw the patient, this step needs to be followed for every patient. You may have gathered all the necessary information by using the software, browsing through the online portal, or even contacting a representative directly via phone and asking them all the right questions. There are times, however, when you may overlook something that could be helpful to the verification process as a whole.
Asking the patient whether their insurance has changed does not give the patient the date of your most current information about them. Rather than assuming all the information is correct, show them everything you have and ask if anything needs to be changed. Once the patient confirms the information you provided is accurate, your insurance verification process is complete. If not, start at the top and this time, ensure not to cut any corners. Else, the result could be a decline in cash flow, a rise in claim denial rates, and a negative impact on patient satisfaction.
A healthy revenue cycle depends on eligibility verification. Nevertheless, you need a backend partner who can help you minimize denials and maximize reimbursements by automating the claims process. Find out more about how we handle eligibility verification seamlessly, in real-time by reviewing our medical billing software – expEDIum or getting in touch with us at here.
