Ten Best Practices for Insurance Eligibility Verification

This article discusses the significance of insurance verification and the best practices for performing insurance eligibility verification.

In today’s fast-paced healthcare environment, it is important for healthcare practices to ensure smooth operations and efficient financial management. Running insurance eligibility checks before providing services is an important aspect. Insurance issues are one of the primary reasons for claim denials, which can lead to significant financial disruptions for healthcare practices. It is important for physicians to clearly analyze the patient’s specific insurance plan. This helps patients to get accurate information about their coverage, plan for their treatments, and thereby avoid unexpected expenses. Ensuring accurate and timely insurance eligibility verification not only minimizes claim denials but also improves cash flow and patient satisfaction. This can make the medical billing process more efficient, thereby raising your overall bottom line. As navigating the details of patients’ coverage and benefits can prove to be challenging, many healthcare practices tend to rely on professional insurance eligibility verification services. Such professionals can help healthcare providers verify patients’ coverage before treatment.

What Are Insurance Eligibility Checks?

In simple terms, insurance eligibility checks confirm whether a patient’s insurance coverage includes the services they seek. Determining the co-pay, deductible, and coverage limits is crucial to avoid medical billing and payment issues. Generally, insurance verification should be done before the beginning of the treatment. This is significant as this would help avoid last-minute surprises for patients, particularly in case of costly procedures.

How to Streamline Insurance Eligibility Verification

Adhering to certain best practices can help healthcare practices streamline the insurance eligibility verification process and ensure operational efficiency.

● Understand the Importance of Insurance Eligibility Verification – As mentioned above, insurance eligibility verification is the process of confirming a patient’s insurance coverage and benefits before services are rendered. It ensures that healthcare providers are aware of the patient’s coverage limits, co-pays, deductibles, and exclusions. Neglecting this step can lead to claim rejections, delayed payments, and increased administrative costs.

● Establish a Systematic Insurance Eligibility Verification Process - A structured approach to insurance verification can help save time and resources. Here are the key steps to incorporate -

● Collect Patient Information Early – The collection of patient information is typically done at the initial point of contact with the healthcare practice. Details to collect include -

? Personal information - Full name, date of birth, address, insurance ID, policyholder information and contact information.

? Verify Insurance Details - Insurance company name, policy number, group number, and the insured party’s details (whether it’s the patient or a family member).

? Check for Limitations - Identify service-specific restrictions, pre-authorization requirements, and out-of-pocket costs.

? Effective Date - Verify the start date of the insurance policy to confirm whether the coverage is active.

? Document Everything - Maintain detailed records of verified information for future reference.

The collection of patient information can be performed during several stages of the patient’s interaction with the practice, based on the specific procedure. Patient information is obtained during the initial registration process for new patients or before each appointment for existing patients, especially if there are updates to their insurance or medical details.

● Verify Patient Eligibility Frequently – It is crucial to verify insurance eligibility before every visit to ensure seamless claims submission and payment. This step confirms the patient eligibility for physician services under the policy. It also checks the specific benefits covered and evaluates co-pays and deductibles. Evaluate any out-of-pocket costs the patient will be responsible for, such as co-pays, deductibles, and annual maximums.

● Verify Insurance Coverage on the Date of Service - Before providing treatment, physicians should verify a patient’s insurance coverage. This can be done by logging into the patient’s insurance portal or by calling the toll-free number on the patient’s identification card. Physician offices can verify eligibility on the date of service by asking patients questions during the visit to check for potential eligibility changes since their last visit, including - if their insurance has changed, if they or their policyholder had any recent employment changes and how long the plan coverage will remain in effect after the employment change, or how the change might affect their coverage.

● Stay Updated with Payer Policies – It is important to familiarize with insurance providers’ policies to comprehensively understand coverage limits and documentation requirements. Regularly review payer updates to remain updated about the type of changes that may impact your billing practices.

● Train Staff and Optimize Workflows - Educate your staff on the importance of insurance eligibility checks and train them on using your eligibility check tools effectively. Optimize workflows to include automated eligibility checks at the appropriate step to ensure consistency and efficiency.

● Adequate Patient Communication - Patients should have complete knowledge about their coverage, including details on co-pays, deductibles, out-of-pocket costs, and which procedures are covered under their plan. If a procedure is not covered, it’s important to clarify whether the patient will be responsible for the charges, based on the terms of their insurance contract.

● Claim Submission – Once the treatment procedures get completed, the next step is claim submission. In most cases, certain treatment procedures are covered under a patient’s medical policy, and often, the medical policy must be billed first.

● Maintain Documentation – Maintaining accurate records of the insurance verification process helps in smooth claims processing, accurate billing, and compliance with insurance requirements. Information to record includes - eligibility verification details and date, changes to insurance providers or policies, updates to coverage limits or benefits, authorization details, communication with the insurer, written communication with the patient on their insurance coverage or treatment estimates and patient consent and acknowledgement.

Insurance authorization and verification services can help home healthcare practices streamline their operations, allowing them to focus on patient care while ensuring timely reimbursement. By efficiently communicating with payers and securing necessary approvals, healthcare practices can deliver care with confidence. Implementing the above best practices for insurance eligibility verification ensures that healthcare providers can deliver continuous care while maintaining financial stability. Collecting patient eligibility information early and collaborating with an insurance verification company are all essential steps to achieve efficiency in this critical process.