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ELIGIBILITY AND BENEFITS VERIFICATION PROCESS

Author: Lavanya Duddu

INTRODUCTION:

Eligibility and benefits of verification process involve whether a patient’s eligible for certain term and condition and verifying the details of patients before patients visits.

The patient data is entered and check verifying age limits and certain criteria

Such as insurance name, phone number and claims address

Name of insured as isn’t always the patient and effective date of policy and end date of policy

If  required team will initiate the prior notice and update the hospital revenue cycle.

Some estimate indicates that many claims are getting rejected are on account of the patients are not being eligible for the given service.

Delayed payments leading to delayed access to patient’s care resulting in low patient satisfaction

Increased claim rejection due to inaccurate or missing data

Decreased collections lead to increased debts

It is most disregarded process in the profit chain.

RESULTS OF INEFFECTIVE ELIGIBILITY AND BENEFITS VERIFICATION

1. Ineffective eligibility and benefits verification leads to increasing claim rejection.
2. Delayed payments leading to delayed access to patient care, resulting in low patient satisfaction.
3. Increased claim rejections due missing patient data.
4. Decreased collections and increased bad debt.
5. Delayed processing time.

To reduce rejections additional effort should keep and patient access to care.

RESULTS OF EFFECTIVE ELIGIBILITY AND BENEFITS VERIFICATION

By  effective Eligibility,

1. The healthcare companies can easily put together claims that can be checked and approved quickly without delay.
2. The service that helps clearly check the coverage validity, primary and secondary payer details.
3. update your practice management system with the approvals and other information received from the payer.
4. claim denial appeals where required.

SERVICES:

• The team experts work together to help accelerate time to time and make client accounts receivable cycle and providers conform the patient’s eligibility and obtain necessary Receive patient schedule from the healthcare provider’s office – hospital
• Perform entry of patient complete information
• Verify coverage of benefits with the patient’s primary and secondary payers:

• 1. Coverage – whether the patient has valid coverage on the date of service
  2. Benefit options – patient responsibility for co-pays, co-insurance, and deductibles

• Where required, the team will initiate prior authorization requests and obtain approval for the treatment
• Update the hospital’s revenue cycle system or the patient’s practice management system with the details obtained from the payer

MINIMIZE DENIALS AND MAXIMIZES PROFITS:

A person who ensures a smooth –sailing eligibility and benefits verification is called an insurance verifier.

The staff work with patients, handle all paperwork and verifying patient information with their own insurance policies.

So that they can facilitate revenue cycle improvement and maximize reimbursement.

Insurance verifiers make sure that given term are verified:

• patient policy status
• co-pays
• claim mailing address
• payable benefits
• types of plan and coverage details
• lifetime maximum

VERIFICATION PROCESS

1. Receive patient schedules from the hospital.
2. Verify the patient’s insurance coverage.
3. Contact patient for additional information.
4. Create member ID, group ID.
5. Update the billing system with all eligibility and verification details such as start and end date.

There are few benefits for outsourcing your  insurance  verification services:

• Reduced effort and time.
• Improved staff productivity.
• Faster billing cycles
• Reduced operational cost
• Simplified workflow

For new patients insurance verifiers should confirm the following:

• Patient’s name and date of birth
• Name of the primary insured
• Social security number of primary insured
• Group number
• Id number
• Contact information for insurance company, including phone number
• Patient mobile number

How does a practice check eligibility?

Practices can use two different methods to verify eligibility real-time eligibility checking or manual checking.

It is a best practice to use electronic real-time eligibility to run checks at least 48hours  before  patient’s appointment

This method allows:

• Gain access to the patient’s insurance status and benefits prior to the visit.
• Verify updated insurance and ensure the account is notated for expedited check-in.
• Ask the patients to update their primary care physician and coordination

Benefits

Medical Billing Wholesalers’ eligibility and benefits verification and prior authorization services offer:

• Save over 40% in operational cost
• Improve speed to care delivery:
• Reduce Claim Denials.
• Reduce Bad Debt, Increase Cash Collection.
• Expertise
• Focus on growing your business

What Is Insurance Eligibility Verification In Healthcare?

Insurance Eligibility Verification is the procedure of verifying a patient’s insurance in terms of three different statuses such as coverage status, active or Inactive status, and eligibility status. Insurance eligibility verification is very important as it is directly linked to claim denials or payment delays of a healthcare practice, especially the account receivables

Insurance Eligibility Verification Process:

The steps involved in the eligibility verification process take place as follows:

1. Patient Scheduling:

With the help of automated appointment scheduling software, the online scheduling features help streamline the scheduling process to a greater extent.

The manual administrative tasks such as appointment reminders through text, call, and mail, and rescheduling of canceled appointments can be automated easily.

2. Patient Enrolment:

Patient information is the core data of the healthcare industry.

But the main thing is what the patient health data must include and what should be omitted.

The basic information like

1. NAME
2. AGE
3. NATIONALITY
4. ADDRESS and medical history

3. Eligibility Verification:

The eligibility verification is the most important step in the RCM process

. If it is done in the right way, it leads automatically to an increase in the number of clean claims.

A smooth insurance eligibility verification process solves major issues like delayed payments, billing errors, and non-payment.

It is important to periodically check the coverage and benefits extended under the patient’s insurance plan.

4. Pre-authorization:

Prior authorization is very important in revenue cycle management (RCM) as payers need to confirm whether a particular medication or procedure will be approved.

If an insurance company does not approve certain treatments or medical equipment, healthcare providers should wait till they get approval, or else they need to contact the insurance providers regarding the approval process.

5. Connecting Patients:

The patient data including basic information, health records, and contact information should be collected prior and should be maintained correctly.

If any additional information is required such as medication details, it’s advisable to contact the patients for accurate information.

5. Billing System Update:

The billing system is where the patient details including the insurance coverage data are updated. Use the advanced verification system to retrieve the insurance card and verify patient eligibility with every visit to avoid claim rejection

6. Claims transmission:

At last the claim submission request is sent to the insurance provider.

 Benefits of Eligibility Verification

1. Improves the Cash Flow

Accurate insurance verification will speed up the claim approval process and ensures you the highest number of clean claims. Thereby, it will lead to improvement in the cash flows via a faster billing cycle. However, inadequate verification of insurance eligibility and plan-specific benefits will enhance your risk regarding the higher chances of claim rejections, bad debt, and even denials.

1. Minimizes Claim Denials & Rejections

You can also minimize your claims rejections and denials by verifying the insurance coverage well in advance for your equipment or procedures.

As the insurance information keeps changing frequently, you really need to stay updated with these ever-changing regulatory requirements.

Otherwise, this could lead to billing errors, rejected claims, and even delays in reimbursements.

As a healthcare provider, you need to be more careful and verify your patient’s eligibility before scheduling an appointment or providing services to them.

EXAMPLES

Example1: a patient comes in for a scheduled sugar test .it is the patient’s fourth-time visit for that particular test

The front desk did not bother about verification of patient eligibility or benefits because this is the patient fourth visit.

A test is costly, so always verify the patient’s eligibility or benefits.

Don’t assume every visit or procedure is covered by a patient insurance because it was approved in the past

In case :

If the visit or procedure is not covered, it may because of

• The patient’s previous insurance coverage was cancelled and is the case, a new application is required
• The patients employer could have changed and also the benefits.
• A new policy is being implemented for the procedure that is being performed

Example 2:

An existing patient comes in for his scheduled visit to have injections.

The patient has been under your care for five years now .upon the front desk ask him to share his card and the contact the insurance carrier for verification and they were informed that the patient is no longer coverage .that’s why always important to verify the each patient’s insurance.

CONCLUSION:

Checking the eligibility of patients and entry the data

Patient scheduling, patient enrollment, Maintaining the  health records, authorization, updating patient information, updating medical billing, claims transmission

Updated eligibility verification help in better claim submission and lesser claim rejection

Benefits: Saving over half of operational cost

Improve speed to care delivery

Focus on growing business

are the important factors included in the eligibility and benefits verification process

References: websites

Medical billing wholesalers, greenway health, cap minds, Dr catalyst