Best Practices for Verifying Insurance Eligibility

Confirm insurance prior to each patient visit with real time eligibility tooling. Be sure that the patient is actively under coverage, co-pays, deductibles and policy. Insure there are no mandatory prior authorizations to prevent the denial of claims. It is always important that verification details be documented, such as: payer response, reference numbers and verification date so that compliance is achieved and reimbursements can be made faster.

One of the most important stages of the revenue collection in medical billing is the confirmation of insurance eligibility. Denial of claims, delayed payment may occur due to failure to verify insurance cover of a patient before services are provided and further patients will be dissatisfied. Checking the eligibility in advance does not only safeguard the revenue of your practice, but also prepares the patient to be aware of what he or she is covered to receive and what he or she is supposed to pay.

We have a closer look at the best practices that can make your insurance verification process efficient, accurate, and reliable.

1. Before each visit ensure Insurance Coverage

The insurance condition of a patient might have changed even when the patient arrives as a follow-up case. Insurance is always double-checked at least 24-72 hours before the visit to have no surprises.

Some of the important things to be checked:

• Active policy status; effective dates
• Kind of coverage (PPO, HMO, Medicare, and so on)
• Co-pays, deductibles and coinsurance
• Referral or prior authorization need
• In network or out of network In-network or out-of-network status

2. Take Real-Time Eligibility (RTE) Tools

Verifications by hand may take a long time. Real-time eligibility (RTE) checks are most often provided by the modern practice management systems or clearinghouses which are linked with the systems of payers.

The advantages of RTE:

• Faster verification process
• Up-to-date benefit details
• Reduced staff workload
• Fewer eligibility-related claim denials

3. Maintain Accurate and Updated Patient Records

Wrong information in patient is among the leading causes of rejection of claims. It is important to develop the practice of checking and revising:

• ID numbers of insurance
• Name of patient (same as they are on their insurance card)
• Birthdate Policyholder relationship
• Number of groups

Scanning tools may be used to append front/back copy of your insurance cards in your EHR to easily refer to.

4. Call the Insurance Company When Needed

Although electronic verification is quick, it might not pick up the complex plan-specific information including:

• Specialty service coverage limits
• Carve-outs of behavioral health
• Second insurance regulations

At times, even in-call clarification conducted via making a phone call to the payer provider line can eliminate expensive billing errors.

5. Document Everything

The reasons lying how and when something in the patient record has been verified appear in the record including the individual who verified it, the time and date of the verification and what was said to be verified and special notes are taken of the verification.

Documentation must be made of:

• Date verification and time verification
• The rep of the insurance (when called)
• Active coverage confirmed
• Marked exceptions or special provisions

This acts as a precautionary step when it comes to conflicts, or in case of a payer mistake.

6. Training Your Front Desk and Billing Personnel

The process of eligibility verification is teamwork. Ensure that your front desk and billing tasks:

• Aware of what to verify and verification instruments usage
• Adhere to a uniform work pattern
• Explain to the patients about their coverage and expenses clearly
• Periodic practice will also keep precision and responsibility in the group.

7. Develop Verification Check list or SOP

Making your verification process standard is useful in order to be consistent. Create a checklist or Standard Operating Procedure (SOP) of your staff which should have:

• Time schedules of verification
• Evidence that prove
• What to do with inconsistencies
• What to do when the coverage is included

This reduces the amount of guesswork and makes it easier to get onboard new employees.

Conclusion

Although it might seem that the insurance eligibility verification process is an administrative procedure, it remains one of the most effective weapons a practice can apply to ensure its financial safety. Claim denials, delayed reimbursement, and frustrated patients are caused by the majority of inaccurate or missed verifications, and all of it can be eliminated by having proper processes set up.

Through diligent verification processes, education of your billing and front-desk departments, and use of the real-time technology tools, your practice can make sure that by the time services are provided, coverage details are verified. Such an active strategy can not only decrease the chances of rejecting claims but also enhance financial transparency between the organization and its patients that would result in higher levels of trust and patient experience overall.