What makes Insurance eligibility verification so crucial in the healthcare world?

Insurance Eligibility Verification- What is the buzz about?

Did you know that two out of five claim denials are related to insurance coverage? As a result, practices lose millions in revenue annually because the eligibility has expired or the plan did not cover the patient. To avoid such losses, practices must invest in a robust insurance eligibility verification process.

With the implementation of the Affordable Care Act, insurance eligibility verification is more important than ever. In today’s insurance eligibility verification reality, an ACA patient can get insurance for one month but not pay their premiums for the next two months. 

All claims for services given in the first month of the grace period must be paid by qualified health plans (eligibility). In the second or third months, carriers will spend claims, at which point the patient must pay the provider for services previously delivered or pay their insurance premium. 

If a patient cannot afford to pay their premium, pending physician claims will go unpaid during the second and third months, increasing bad debt collections. Obtaining a patient’s insurance eligibility verification is required to ensure that the patient is covered, that services are covered, that denials and appeals are avoided and that payments are expedited at the correct rates. 

Denied claims owing to no current coverage, out-of-network, or illegal patient treatments or visits can result in a significant income loss and should not be ignored.

The process of medical insurance eligibility verification- What comes before and after

Medical insurance verification is a fundamental part of revenue cycle management. Understanding how eligibility verification work is crucial to understanding what is involved in the entire process.

Patient scheduling

Using automated appointment scheduling software tools can help practices streamline the scheduling procedure to a more significant level. With most practices shifting towards an automated workflow, patient scheduling has become much more efficient and accurate. 

Manual administrative operations can be easily automated, including appointment reminders through text, phone, mail, rescheduling, and canceled appointments.

Patient enrolment

Patient data is the most vital data in the healthcare industry. The primary point is determining the type of patient health data to be included and the data that should be excluded. For example, a patient’s basic information, such as name, date of birth, address, diagnosis, allergies, and medical history, is critical. 

Practices can record patients’ contact information elsewhere under different headings, such as an emergency contact, a family doctor, and an insurance provider.

Eligibility verification

Then comes one of the core components of RCM- Eligibility verification. If done correctly, it will undoubtedly increase the number of clean claims. A simple insurance eligibility verification process resolves delays in payments, billing errors, and non-payment.

It is critical to regularly review the patient’s insurance plan’s coverage and perks. Practices should keep a thorough patient data record because changes in marital status, birth, and divorce might affect coverage and benefits. 

In addition, it’s a good idea to remind the patient about perks like copays and deductibles throughout the procedure, all through the organization’s administration.

Pre-authorization 

Prior authorization is crucial because payers need to know if a specific medicine or treatment will be approved. For example, suppose an insurance company refuses to approve specific treatments or medical equipment. In that case, healthcare professionals should either wait until they do or contact the insurance company to inquire about the approval procedure and take the appropriate actions.

Connecting with patients

All patient information, including basic information, medical records, and contact information, should be acquired and kept up to date. If further information, such as medication data, is required, it is best to contact the patients for precise information.

Keys to an efficient insurance verification process

Every practice should ensure that there is no scope or error. If you want to make the insurance verification process a success in the long term, practices should follow several cues for guaranteed success.

1. Make a checklist

During insurance verification, ask the correct questions. Front office staff should enter information from the insurance card, phone calls with the insurance company or electronic eligibility systems. In addition, practices should include other details in each patient’s electronic medical record for insurance eligibility verification:

• Name of the insurance company, phone number, and claim address
• An insurance identification number and group number
• Name of insured
• Relationship between the insured and the patient Policy start date
• Policy expiration date
• Is coverage active at the moment?
• Whether the operation, diagnosis, or services to be delivered are covered by insurance.
• Whether or not your practice participates in the plan
• Limitations of the policy
• Whether payment requires a referral or a pre-authorization proof of the medical necessity
• The patient’s copay and deductible amounts

2. Get a copy of the insurance card

Begin collecting insurance eligibility verification information by requesting a copy of the patient’s updated insurance information. Even if the patient claims that their insurance hasn’t changed, requesting a copy of the card is a good idea. 

If someone mistyped insurance information in your electronic health record, an updated photograph on both sides of the insurance card gives an informational backup. Before sending claims, medical billers should double-check ID numbers against cards.

3. Contact the insurance company

Take the information on cards with a pinch of salt. Insurance coverage may have changed or been canceled even a few weeks after an issued card. To ensure that the patient is eligible, contact the insurance carrier directly. Call the payer’s provider hotline, or utilize your integrated EMR and billing system to ping more significant payers like Medicaid, Medicare, or Blue Cross for eligibility information. 

It is the most efficient approach when you can set up electronic eligibility systems for payers. Then, you may be able to immediately import data into electronic medical record systems, speeding up the procedure and reducing the risk of data entry errors.

4. Accurate information is the key

Educate office personnel to be extra cautious when entering data into patient records. The data is the basis of the medical claim, and a single flipped number can spell the difference between a successful claim and a refusal. 

Rushing through insurance verification procedures and committing data errors can result in days or weeks of payment delays. In addition, the claim could go unpaid, which is problematic for any medical practice.

An easy and efficient way out- Outsource

Practices can avoid delays and denials of insurance claims by outsourcing a critical procedure like insurance eligibility verification to a service provider with an experienced team of medical billing and coding professionals who are up to speed on all the latest health plans and policy changes. 

For nearly a decade, Capline Services has provided fast, efficient, and best-in-class eligibility verification services to practices across the United States. Our cost-effective services, including RCM, eligibility verification, and health insurance credentialing services, enable clients to focus on their core operations while providing better patient service. 

We use a streamlined verification procedure through our medical insurance software to maximize claim acceptance and decrease denials and write-offs. By outsourcing insurance eligibility verification to us, you can expedite the processing of your medical claims and enhance your cash flow.