Best Practices: Patient Eligibility & Benefits Verification

With rising consumerism, patients are taking on more financial responsibility. The rise of high-deductible health plans (HDHPs) is a prominent evidence of this trend. As a result, it is critical to determine coverage and fully define the patient’s responsibilities for upfront payments.

This essay emphasizes the significance of patient eligibility and benefits verification.

What is patient eligibility and benefits verification?

A healthcare practitioner must check the patient’s coverage for medical treatments and assess their financial liability. Physician practices can check the coverage provided by the health plan as well as copayments, deductibles, and co-insurance with the health plan through the patient eligibility and benefits verification procedure.

Verification of eligibility encourages the collection of coverage status and minimizes the likelihood of claims being denied. It enables healthcare providers to receive payments from patients in advance and avoids cash realization delays.

Information should be submitted for patient eligibility and benefit verification

One of the most important aspects of front-office work is gathering patient information ahead of time so that insurance verifiers can verify benefits.

Healthcare providers must educate their employees on the insurance verification processes. Processing efficiently decreases the likelihood of denials and speeds up the cash flow cycle.

Electronic and manual eligibility verification processes

Most payers have made online eligibility checkers available. You will be able to save time by electronically checking eligibility prior to the planned patient appointment.

  • Obtain correct information about the patient’s insurance status and comprehend the health plan’s benefits.
  • Determine whether or not you must collect a co-pay at the time of service.
  • Update insurance information
  • Request that patients update their primary care physician information.

It is sometimes necessary to contact the payer with inquiries about prior permission requirements or to clarify specific eligibility and benefits features.

Timeliness of eligibility checks

Healthcare providers must do an eligibility check at least 48 hours before the visit. If this is not possible, it can be done in real time before the treatment during check-in. Eligibility checks performed on time might help you reduce claim rejections and denials. Electronic eligibility verification is available in most electronic health records and revenue cycle management systems. Your clinic can reduce denials and enhance revenue realization by validating the patient’s coverage prior to treatment delivery.

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The importance of process documentation

Your practice’s requirements are distinct. A substance abuse treatment center’s eligibility verification requirements are quite different from those of a hospital or radiology clinic. As a result, each institution must develop its own eligibility and benefits verification protocols. All members of your team must work together successfully to guarantee that all steps are completed efficiently.

Checklist for Verifying Eligibility

The following are some best practices for determining patient eligibility and verifying benefits:

  • Check to see if the plan is still active.
  • Always inquire about any upcoming or recent insurance changes with the patient.
  • Check to see if the patient has main, secondary, and tertiary insurance. Ascertain that the patient’s Coordination of Benefits (COB) with each payer has been updated.
  • As a large portion of the population in the United States ages, check Medicare coverage for patients over the age of 65.
  • Determine whether you require prior authorization or a referral for the specific medical procedure. Please get referrals or authorizations as needed and update the revenue cycle system.
  • Confirm if the patient’s insurance policy covers the procedure.
  • Some plans may limit the number of visits and time frames in which medical services can be provided, as well as the benefit limits. These details must be obtained through the front office.
  • Certain services, such as behavioral and mental health, substance misuse, and addiction, may necessitate contacting the insurance company. You may be unaware of these criteria and will need to consult payer-specific guidelines.
  • Patient responsibility for payments. Collect the payments for deductibles, copayments, and co-insurance based on the policy details. Pursuing patient collections can be tedious, and you must collect as much upfront as stipulated.
  • Additional information

The social determinants of health are becoming an important component of care delivery because they promote healthcare equity and access. Race, gender, ethnicity, date of birth, preferred language, and other characteristics are required for Meaningful Use reporting. These traits are also important in health equity research.

Outsourcing Eligibility and Benefits Verification Process

An outsourced service provider can assist you with the eligibility and benefits verification processes. Their training techniques assist you in obtaining experienced staff at a lower cost and reducing the workload on your revenue cycle team. Some of the advantages of outsourcing include:

  • Free up your staff’s time to focus on other patient experience and revenue cycle duties
  • Accelerate care delivery
  • Reduced denials and increased cash flow
  • Labor rate arbitrage reduced costs
  • Policies and procedures that are kept up to date
  • Shifting the emphasis to denial avoidance through minimizing the number of eligibility and benefits-related denials

Medical Billing Wholesalers eligibility and benefits verification competencies

Efficient eligibility and benefits verification services are critical to the financial health of your firm. The process is also responsible for the majority of claim denials. You must always develop and learn from each denial. Medical Billing Wholesalers provides experienced revenue cycle professionals to assist your front-office staff with eligibility and benefits verification.

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