Did you realize that insurance coverage is a factor in two out of every five claim denials? Because the patient's eligibility has expired or the plan did not cover them, practices lose millions of dollars in revenue every year as a result. Practices must invest in a strong insurance eligibility verification process if they want to prevent such losses.
Insurance eligibility verification is more crucial than ever in light of the adoption of the Affordable Care Act. An ACA patient can obtain insurance for one month while failing to pay their payments for the following two months in the current insurance eligibility verification reality.
Qualified health plans are required to pay for all claims for services rendered during the first month of the grace period (eligibility). Carriers will spend claims in the second or third month, at which point the patient will either need to pay the physician for previously rendered services or pay their insurance premium.
The amount of bad debt collections will rise if a patient is unable to pay their premium, which will result in unpaid pending physician claims in the second and third months. To make sure that a patient is insured, that services are covered, that denials and appeals are prevented, and that payments are expedited at the appropriate rates, it is necessary to obtain a patient's insurance eligibility verification.
Denied claims resulting from lack of current coverage, out-of-network treatments, or unethical patient visits or treatments can cause a large income loss and should not be disregarded.
What happens before and after the medical insurance eligibility verification process
Verifying medical insurance is an essential component of revenue cycle management. Understanding how eligibility verification functions is essential to comprehending the entire process.
Planning for patients
Practices can streamline the scheduling process to a greater extent by using automated appointment scheduling software applications. The majority of offices are now using automated workflows, which has greatly improved the efficiency and accuracy of patient scheduling.
The scheduling, rescheduling, and cancellation of appointments, as well as appointment reminders sent through text, phone, or mail, may all be readily automated.
Enrolment of patients
The most important data in the healthcare sector is patient data. Choosing which patient health data should be included and which should be removed is the main consideration.
For instance, it's crucial to know a patient's basic details, including name, date of birth, residence, diagnosis, allergies, and medical background.
Practices can keep a record of patients' contact information in other places under several titles, including an insurance company, a family doctor, and an emergency contact.
Verifying eligibility
The next step in the RCM process is eligibility and benefits verification services. It will surely boost the amount of clean claims if done properly. Delays in payments, billing problems, and non-payment are all fixed by a quick insurance eligibility verification procedure.
Regularly reviewing the patient's insurance plan's benefits and coverage is essential. Because changes to a patient's marital status, child's birth, or divorce may have an impact on coverage and benefits, practices should maintain a complete patient data record.
Furthermore, it's a smart notion to keep the patient informed about benefits like copays and deductibles at every stage of the operation, all the way through the organization's administration.
Pre-authorization
Prior approval is essential because payers need to know whether a particular drug or treatment will be accepted. Consider the scenario where an insurance provider declines to cover particular medical procedures or equipment.
Healthcare providers in that situation should either wait until they do or get in touch with the insurance provider to learn more about the approval process and take the necessary steps.
Linking up with patients
It is important to gather and maintain the accuracy of all patient data, including contact details, basic information, and medical records. It is preferable to get in touch with the patients for exact information if more details are needed, such as medication information.
The essentials of a successful insurance verification procedure
Every procedure should make sure there are no gaps or errors. Practices should adhere to a few indicators for surefire success if you want the insurance verification process to be a long-term success.
1. Create a list
Ask the right questions during the insurance verification process. The front desk employees should input data from computerized eligibility systems, phone calls with the insurance provider, and insurance cards. Additionally, for the purpose of confirming insurance coverage, practises should include the following information in each patient's electronic medical record:
- Name, contact information, and claim address for the insurance provider
- A group number and an insurance identification number
- The insured's name
- Patient-insured relationship Start date of the policy
- Date of Policy Expiration
- Is coverage currently active?
- Whether the procedure, the evaluation, or the forthcoming services are covered by insurance.
- Regardless of whether your practise takes part in the plan
- Policy restrictions
- if a referral or pre-authorization is necessary for payment; evidence of the medical necessity
- The copay and deductible for the patient
2. Obtain a duplicate of the insurance card
By acquiring a copy of the patient's most recent insurance information, you can start gathering data for insurance eligibility verification. Even if the patient insists that their insurance hasn't changed, it's a good idea to ask for a copy of the card.
An updated photo on both sides of the insurance card provides informative backup in the event that someone typed the wrong insurance information into your electronic health record. Medical billers should double-check ID numbers against cards before sending claims.
3. Speak with your insurance provider
Be skeptical of the information on cards. Even a few weeks after a card was issued, insurance coverage could have changed or been terminated. Make immediate contact with the insurance provider to confirm the patient's eligibility.
For eligibility questions, contact the payer's provider hotline or use your integrated EMR and medical billing services system to ping larger payers like Medicaid, Medicare, or Blue Cross.