Patient Eligibility Verification in Medical Billing and its Significance

Healthcare is expensive in the country, and with the help of insurance companies, the majority of the citizens can get help with increasing healthcare costs. There are many severe repercussions if a patient is unable to pay for the service. It is paramount in sustaining a good revenue cycle. Hence, knowing the patient benefits and financial responsibilities before services can allow the practitioners to fill the large gaps by decreasing A/R days after billing. There are certain times that revenue gets lost and will cause a domino effect on reimbursement. Thus, it is indispensable to verify eligibility every time the patients come in for the service.

What is the Verification Process?

The verification process starts before an individual approaches the healthcare facility seeking  treatment. For timeliness and clean claim submissions, practitioners verify the insurance eligibility and make sure that they get paid for the services incurred as per the insurance coverage policy. For eliminating any scope of claim rejections, insurance verification begins before the first appointment to the course of treatment and subsequent follow-ups under the insurance plan.

However, there is a thorough authentication process which starts with the patient coverage, the services and benefits the plan covers, coinsurance, deductible, copayments, and pre-authorization requirements for medical treatments. Additionally, both the patients and the practitioners can focus on specialized treatment without the financial burden.

Why Insurance Eligibility Verification Important?

Verifies the active coverage in advance to estimate the total medical cost for the treatment. Prior estimation for the medical expenses will help the patients to figure out the payment plans. Mostly, the patients don’t know about their deductibles and active coverage plans, and for this reason, they end up paying enormous amounts. Health insurance verification services ensure that the policy covers the treatment the patient needs, and the practitioner gets paid without a hitch.

Steps involved in Patient Eligibility Verification

There is always a situation when a service provider reschedules a patient’s appointment because of showing up without payment. The excellent reason for the insurance verification begins with receiving the schedules of patients and collecting the information beforehand.

For an impactful revenue cycle, below are the steps to ensure there is no scope of mistakes and information gaps.

1) Insurance Verification Checklist:
That is the first and foremost process of gathering details about the patients such as patients name, date of birth, address, insurance carrier’s name, ID number, social security number, and information about their insurance coverage- the type of plan, coverage details, policy status, pre-authorization, applicable co-pays, deductibles, and-so-forth. To verify and confirm the patient background, the dedicated staff should connect with the insurer that eventually affects the planning of the treatment and also if needed for any pre-authorization or referral.

2) Verifying the Insurance Card:

Insurance card re-surfaces and reveals the vital information required to ascertain the eligibility, insurance coverage, current benefits, and the insurance network of the patients to eliminate any scope of claim rejections. Besides this, the payer can inform the practitioner about the policy limitations, deductibles, documentation, coinsurance responsibilities, and applicable co-pays, etc., to know the condition of getting the claims approved.

3) Contacting and sharing information with the Patients:

That is the critical step of the medical claim. Hence all the vital details of the patient are recorded in the pre-set format. The process is standardized as per HIPAA compliance to eliminate any technicalities. Furthermore, for the progress and the clarifications, the patient must be kept in the loop. Therefore, the patient can ponder upon the right treatment decision as well as get time to arrange money to afford the services.

Thus, to avoid any delays and easy exchange of information, practitioners must leverage:

• Patient portals
• Cloud storage
• Robotic Process Automation

Once the necessary data has been collected and shared, this will help you accelerate your billing cycle as a result.

Vulnerabilities of Patient Eligibility Verification Process

Patient eligibility is planning on paying for services that you are currently providing to a patient. Thus, below are the major pain points to the conventional patient insurance verification process.

Manually following the process: Each insurance verification process requires a set of specific tasks. Such as verifying patient’s data through insurance cards, calling the insurer, and manually maintaining the personal information of patients requires persistent efforts to ensure it is error free.

Long turnaround time: As the verification process involves multiple tasks, if not handled by specialists with quality services, this would take a hit in the revenue flow viz a viz the continuity of operation.

Frequent change in Policies: The health insurance sector is volatile and characterized by rapid modifications in terms and regulations of the policy, which makes it hard to get it right at the first attempt. For this, medical practitioners have to have the right infrastructure and dedicated staff to expedite the claim approvals for their clients.

High operating cost: The erroneous nature of this process requires dedicated employees to execute the job satisfactorily. On occasions, the process relies heavily on resubmissions and rectifications. The payment cycle is long, and no medical practitioner wants to lose the money they deserve. To keep the revenue wheel moving, medical practitioners do not have much scope for cost-cutting.

The journey is robust, but a reliable & professional partner by the side can help you climb the growth curve easily. A well planned and streamlined eligibility verification process will not only increase your efficiency but will ensure unhindered cash flow and a better experience for the patients.