Insurance Eligibility Verification – Steps to Reduce Claim Denials

Insurance Eligibility Verification – Steps to Reduce Claim Denials The article discusses the importance of the insurance eligibility verification process and the different steps involved.

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With the healthcare industry witnessing several prominent changes, it is imperative for medical care providers to understand the importance of insurance verification services.

Real-time eligibility and benefits verification helps to simplify and streamline the billing and collection process for healthcare providers. Healthcare insurance verification involves verifying a patient’s eligibility or active coverage with the insurance company and validating his/her eligibility for insurance claims. Having in place a solid insurance verification process can help practices increase revenue and reduce their accounts receivable cycle by significantly reducing the impact of claims denial (due to ineligibility). With such a reliable process, medical billing becomes more efficient.

A2012 study published in the New England Journal of Medicine, the Institute of Medicine (IOM),found

that

the

United

States

spends

$361

billion

annually

on

healthcare

administration —which is more than twice the nation’s total spending on heart disease and three times spending on cancer. An average U.S. physician spends 43 minutes a day interacting with health plans about payment, dealing with formularies, and obtaining authorizations for procedures. A significant portion of administrative costs are directly related to not performing correct insurance eligibility verification or errors in verifying details about patient eligibility.

How does the process of insurance eligibility verification work?

The verification process must be done before the patient is admitted to a hospital, or else it may lead to claim rejection. As a general rule, both new and returning patients should bring their insurance identification card or other relevant documents for each of their visits. A simple error like providing wrong or outdated information or not informing when their policies have been terminated or modified can result in claim denial. The prominent role of health insurance verification specialists (also called insurance verifier) in the health insurance domain comes at this juncture. Many medical practices rely on these professionals who closely work with patients to verify patient information with the provider, check whether the card details are up-to-date and correct for that particular date of service and complete paperwork to maximize reimbursement and facilitate revenue cycle improvement.

Outsourcing this important process will help to reduce administrative costs, decrease losses; improve collections thereby enhancing patient satisfaction. In reputable medical billing companies, the insurance verification specialists have vast experience working with both commercial and government insurance companies and can offer customized patient eligibility verification services for all medical practices.

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The following are some of the important steps to reduce the chances of eligibility-based denials ✓

Create a verification checklist – Verifying patient eligibility before the patient is seen by the physician will reduce the number of denials. In fact, a report published

by Managed Healthcare Executive notes that 48% of denials arise from the patient access points and is often caused by the practice staff failing to verify insurance coverage. The following details are to be checked or verified during the insurance eligibility verification process – •

Patient’s name and date of birth

•

Name of primary insurer

•

Social security number of primary insured

•

Insurance carrier

•

ID number and Group number

•

Insurance company’s contact information including phone number, website and address for submitting claims

•

Insurance coverage date

•

In-network or out-of-network coverage

•

Whether pre-authorization and/or a referral by a primary care physician is required

✓

•

Co-pay amount, if any

•

Deductible amount and how much has been met so far

•

If the policy is in danger due to non-payment of premiums

Obtain a copy of the patient’s insurance card - Start the process of collecting information by asking for a copy of new insurance information from the patient.

Enter an updated image of both sides of the insurance card in EHR as this may act as an informational backup in future in case someone mistyped or entered the wrong details in to the record. Medical billers need to double check ID numbers against cards before sending claims.

✓

Contact the insurance provider - Always contact the insurance provider to confirm the eligibility of the patient. In certain cases, the insurance coverage may have changed or discontinued just a few weeks after the date of the card issue.

✓

Record accurate and precise information - Front office staff must check whether the information on the card is correct and up to date.This can be checked with the insurance company’s website or by calling a representative.The information recorded

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builds the foundation of the medical claim and even a small or simple error can lead to claim denial. ✓

Follow up with the patient –Follow up with the patient about insurance information, if there are any specific doubts or questions. Use the patient portal to inform patients regarding their eligibility, co-pays and other details via email.

Verifying or conducting patients’ insurance eligibility and coverage is the primary step that helps to maintain the financial well-being of the medical practice. Prior insurance verification is a strong indicator of Accounts Receivable (AR). The medical practice staff can communicate this information to the patients well-in-advance of their appointment. If timely verification is not performed, it will lead to increased administrative costs.

www.outsourcestrategies.com

(800) 670 2809