Insurance eligibility verification is a process utilized to pre-determine the patient’s insurance coverage and its resultant benefits before providing healthcare services. This verification mechanism ensures that patients receive the right care without financial surprise and that providers get paid. Verification of a patient’s insurance coverage and benefits in advance of their visit helps providers avoid claim denials, delays payment and improves the experience for the patients. Medical insurance eligibility verification will go a long way in ensuring that providers and patients pay attention in the meantime. In this blog post, we will take a closer look into insurance eligibility verification. Stay connected with us till the end!
Health Insurance Eligibility Verification
The eligibility of health insurance verification involves determining the patient’s insurance coverage and the determination of whether or not the insurance will pay for the services provided. It is a very important process in medical billing because it helps in determining the criterion for the coverage, while the determination of patients’ financial responsibility becomes possible.
Determining in advance patent eligibility and benefits helps the healthcare provider with an idea of what to expect from the insurance payer toward a particular medical procedure. It helps avoid any confusion down the road, excludes any surprises, and also ensures in good time an accurate bill for the client.
Process of Health Insurance Eligibility Verification
There are the following steps involved in health insurance eligibility verification:
Collect Patient Information
The receptionist will collect demographic data and insurance data about the patient, including the name of the patient, date of birth, policy number, and group number. We also need the contact information data like phone numbers and addresses for proper communication and billing purposes.
Verify Patient Identity
We would identify the patient in care by photo ID, insurance card, and other tools that can help prove the real identity of a patient. We will also re-check the information we provide against their medical records for completeness and consistency. We could also ask for personal information about them, like an address or phone number, to validate their identity.
Verify Eligibility and Benefits
It will be necessary to confirm the patient’s eligibility for medical services, including services covered, deductibles, copayments, limits of out-of-pocket, and provider status. If there are any specific CPTs related to SOP, we verify those too. Then we verify prior authorizations concerning our intended services, in case there may be some problems with delay in the treatment.
Obtain Authorization
Obtain Authorization: In the event of the requirement for prior authorization by an insurance provider for certain medical services. The provider must obtain the necessary authorization and referral to the service in question. We will also ensure that all documents are submitted on time to avoid lapses in patient care.
How To Verify Insurance Eligibility and Benefits?
To confirm your insurance coverage and benefits, complete these steps:
- Verify active status; insurance applies to those services that you are about to provide.
- Identify specific benefits covered, services, procedures, and medicinal.
- Verify the responsibility of the patient, deductibles, copayments, and co-insurance.
- Identify any service requiring prior authorization and referral.
- Note the reference number, name of the representative with whom you spoke, and date.
- Inform patient of their coverage and out-of-pocket expenses.
Criteria For Eligibility Verification Check
1-Patient Eligibility Verification
One of the very important steps in the medical billing process involves verifying a patient’s eligibility in advance, which may include insurance coverage and benefits verification before servicing the patient. During verification of eligibility, verification for the insurance cover of a patient under the insurance company for the services needed will be done.
It normally entails some validation of the patient’s insurance identification, dates of coverage, what treatments are listed and confirmed to be covered, and what copayments, deductibles, or co-insurance are applicable. To obtain this information, you will most likely use web portals, direct insurance firms, or clearinghouses. Thus, the patient will avoid unwarranted denials and payment delays.
2-Medical Eligibility Verification
It normally entails some validation of the patient’s insurance identification, dates of coverage, what treatments are listed and confirmed to be covered, and what copayments, deductibles, or co-insurance are applicable. To obtain this information, you will most likely use web portals, direct insurance firms, or clearinghouses. So, you will avoid unwarranted denials and payment delays.
- Verification of the patient’s insurance policy, including all benefits, copayments, deductibles, and prior authorization requirements of the services provided. One should verify that the policy is current and active for services provided.
- Verification of patient information about insurance and identification numbers for services performed helps minimize denials and delays in claims.
Eligibility and Benefits Verification in Medical Billing
To decrease denials and potential delays in revenue, the insurance eligibility verification process is vital to a patient’s coverage before the visit using your EHR’s electronic eligibility feature.
Beyond that best practice, follow this checklist before the visit:
- Identify inactive plans and alert accounts.
- If a patient has multiple insurance policies, remind them to update their COB with each payer.
- Verify if patients 65+ have “traditional” Medicare coverage.
- Confirm patient insurance coverage and any necessary referrals or prior authorization.
- Check that referrals and authorizations are accepted, recorded into the system, and linked to appropriate appointments.
- Ask if the patient’s insurance has changed, including new policies or coverage changes.
Why Is Insurance Verification Important?
Despite financial burdens, the healthcare business aims to provide medical treatment to everyone. Therefore, many hospitals have teamed up with insurance companies to offer health care insurance to those who cannot afford basic medical care. On the other hand, there is a good possibility of a medical claim being forged and, therefore, may be rejected or create a nuisance.
i-Identification of True Claims
Verification allows the hospital to establish whether a claimed insurance claim by the patient is valid or not. In other words, the verification process is concluded only after cross-checking the information given by the patient. The verification process helps to determine and establish eligibility for a claimed insurance by the patient. The active or inactive status and the coverage status of the claim are also identified through it.
ii-Preventing Denials and Fraud
The insurance company must authorize insurance claims. If they are not authorized, the payer is not liable to pay anything. Therefore, if you go to the insurance payer with an insurance claim without authorization, you will not get the money. More significantly, the EOB, when combined with the insurance claim, could get the policy denied. Under such conditions, insurance verification can help prevent refused claims because, in the process of verification, one must assess.
iii-Maximum Reimbursement
Insurance verification assures optimal compensation for insurance claims by preauthorizing them, avoiding fraud, and preventing any denials. That means hospitals and doctors get paid for medical insurance verification services they have provided to the patients having insurance claims. The continuous cash inflow ensures that the hospital can invest in different medical specialties by getting new medical equipment.
The Bottom Line
Insurance eligibility verification deals with the confirmation of the patient’s insurance, how many benefits are covered, and who is eligible for such benefits so that it might facilitate timely payment without rejection of the claim. The rules and regulations of insurance are very complex; hence, healthcare providers find difficulties in the verification process; which results in errors in billing and dissatisfaction among patients. Thus, it follows that verification of insurance eligibility provides a very critical chance for the improvement of patient experience and strict adherence to regulation, apart from reducing claim denials. To avail of the medical billing services from a reliable resource, you may trust MAVA Care. We are here to resolve all your concerns related to coding to follow up and cover every minor aspect though.
