Insurance Eligibility
Verifying insurance eligibility is crucial in healthcare revenue cycle management. When a patient schedules an appointment, the provider’s office staff must check if their insurance coverage is active and valid for the date of service. This involves contacting the payer to confirm specifics like the policy holder’s name, plan type, effective dates, expired or terminated policies, out-of-network restrictions, and more.
Documenting eligibility details helps prevent medical claims from being rejected or denied due to lapsed coverage or benefit exclusions. It also provides details needed for accurate billing like copays owed. Checking eligibility in advance allows resolving any discrepancies before care is rendered. Performing a real-time eligibility check is a best practice to avoid issues that disrupt smooth reimbursement.
Office staff must confirm active coverage eligibility and details with the patient’s insurance payer prior to administering any services. This involves checking the status of the policy, deductible amounts met, copay and coinsurance obligations, network participation restrictions, and prior authorization requirements.
Verification is typically done electronically through payer provider portals or phone systems. Confirming benefits helps prevent issues with reimbursement, surprise patient bills, and claim denials further downstream in the revenue cycle. Doing a thorough insurance verification and documenting the details helps ensure smooth billing and payment for rendered services.
Why Eligibility and Benefits Verification Matters
Confirming if a patient’s insurance is active and their covered benefits helps in several key ways:
- Ensures services you provide are covered to avoid non-payment. This helps the patient avoid unexpected bills.
- Allows collecting the proper patient responsibility amounts upfront like copays.
- Flags coverage changes like switched policies, expired plans, or newly added dependents. This prevents rejections.
- Provides details needed to bill services correctly and maximize reimbursement.
- Allows obtaining referrals or authorizations required by the payer before care. Doing this prevents authorization-related claim denials.
In short, robust eligibility and benefits checking early on helps prevent claim submissions from being rejected or paid incorrectly, saving endless headaches down the road.
Best Practices for Eligibility Verification
Follow these best practices to verify eligibility like an expert:
- Verify coverage on the actual date of service, not just the day you check. Eligibility can change daily.
- Re-verify for each encounter. Don’t assume the information carries over from one visit to the next.
- Get eligibility directly from the payer when possible versus relying on patient statements alone. Data can differ.
- Check both primary and secondary insurance coverage when applicable.
- Confirm eligibility electronically and print/save responses to have on file. Unlike phone verification, you can document the details.
- Review name, DOB, and policy number against card presented to ensure an accurate match.
- Watch for red flags like inactive plans, exhausted benefits, and more that could lead to denied claims and avoid services in those cases or have the patient pay upfront when possible.
Mastering Benefits Verification
Along with eligibility particulars, checking benefits helps answer:
- Is there coverage for the specific service being rendered and diagnosis?
- Do any frequency limits apply, like annual maximums?
- Does the service require prior authorization or referral first?
- What is the member’s cost-share (deductible, coinsurance, copay) responsibility?
- Are there any relevant exclusions or limitations?
- Which CPT and diagnosis codes are covered?
- What is the reimbursement rate/allowed amount?
Having these benefit specifics avoids surprise claim denials and helps set proper patient financial expectations.
Steps to Verify Eligibility and Benefits
Here is a step-by-step process to verify eligibility and benefits:
- Have the patient complete registration paperwork including insurance details. Obtain copies of their insurance cards as well.
- Ask about any recent coverage changes, lapses, new dependents on the policy, etc. that you need to capture.
- Use the insurance website, app, or call the carrier’s automated verification line or live representative to check eligibility status on actual date of service. Get reference number.
- Confirm pertinent member details like name, DOB and policy number match the insurance card presented.
- Review effective dates – when coverage starts and ends. Make sure there are no gaps.
- Note any red flags like inactive plans, exhausted benefits, termination notices that could lead to denied claims. Alert the patient to pay upfront if issues found.
- Verify cost-sharing details like deductible (if met, remaining), copays and coinsurance. Prepare to collect upfront from patient.
- Check for needed referrals, authorizations or pre-certifications and obtain if required.
- Identify frequently used diagnosis and procedure codes that are covered or excluded.
- Ask about specific benefit limits if care is frequent, like 10 chiropractic visits annually.
Where to Verify Eligibility and Benefits
There are a few options to complete eligibility and benefits verification:
- Payer website – Create an account to check details in real-time. Often the quickest option.
- Payer portal – Similar to the website but offers added features like file submissions or status checks.
- Automated phone line – Call the payer’s verification line and follow prompts to enter member data.
- Live representative – Speak with an agent to obtain eligibility information. More time consuming but can ask detailed questions.
- Apps – Major plans like UHC offer mobile apps to check on the go.
- Vendor solutions – Outsource verification tasks to companies like Experian, Change Healthcare, and other partners.
Start by checking payer websites which tend to be the fastest and most direct option in many cases. For more complex cases, calling in works better.
Key Eligibility and Benefits Details to Gather
Be sure to carefully note these key details during eligibility and benefits verification:
- Patient name, DOB, gender – Must match card/records exactly
- Policy number, group number
- Effective date and termination date of coverage
- Copays, coinsurance and deductibles with accumulators
- Visit limits for time period
- Needed referrals or authorizations
- Non-covered services or exclusions
- Codes tied to diagnoses that are approved
- Reimbursement rates for services
- Network limitations and tiers
Tracking all these specifics on a standardized form or in billing systems prevents having to recheck details repeatedly. Print or save verification responses as backup. Make notes of any unclear areas to pursue further confirmation.
Top Eligibility and Benefits Verification Errors
Watch out for these common mishaps:
- Failing to re-verify eligibility at each visit. Patients can churn on and off plans.
- Not verifying secondary payer benefits. Both payers must be checked.
- Using old eligibility data stored in patient charts from prior visits. Information goes stale.
- Relying on patient verbal summaries alone. Get confirmation directly from the payer.
- Generic eligibility checks without digging into covered and excluded benefits for planned services.
- No authorization obtained when required leading to denied claims.
- Incorrect patient cost share collected upfront. Amounts should match verification findings.
- Typos in names or policy numbers. Information must match card/payer records exactly.
- Failure to note restrictions like out-of-network limitations and expired referral periods.
- Double checking your work helps catch mistakes early while you can still rectify issues pre-visit.
Leveraging Technology for Smarter Verification
Technology makes verifying eligibility and benefits much easier with tools like:
- Patient portals to directly submit updates that sync with billing systems. Reduces manual entry and paperwork.
- Integrated EHRs that verify details in the background based on appointment scheduling.
- Automated voice confirmation calling. Patients “press 1” to confirm details from their IVR call automatically.
- Real-time benefit checking APIs that sync details directly with practice systems.
- Cloud faxing of forms patients complete in advance from home reduces fielding incomplete forms.
- Flagging duplicate patient records that create confusion on policy details.
The more verification tasks that technology can reliably automate, the greater billing team productivity and accuracy.
Best Practices for Outsourced Verification
If outsourcing eligibility and benefits verification, make sure vendors follow essential protocols like:
- Verifying each patient for every single encounter without fail. One-off checks create risk.
- Obtaining reference numbers during verification to prove checks performed.
- Updating patient insurance data in real-time to avoid stale information.
- Easy transfer of details from verification datasets into billing system or EHR claim records.
- Identifying red flags for staff to address like terminated policies.
- Adhering to HIPAA regulations and securing sensitive patient information.
- Detailed auditing to ensure vendors consistently complete quality verification.
Even when outsourcing, staff should still periodically check some records internally to audit vendor performance.
Summary
Thorough insurance eligibility and benefits verification is crucial for accurate claim submission and reimbursement. Following protocols to check details before each encounter and digging into covered benefits helps minimize rejections and rework down the road. Leverage payer technology and outsourced services to reduce tedious paperwork and manual processes where possible. Consistent, high-quality verification lays the foundation for billing and payment success.
