Insurance Eligibility Verification

Insurance Eligibility Verification is an important process wherein a provider’s practice, healthcare facility checks into a patient’s insurance eligibility or coverage to know if the patient can avail healthcare benefits, consultation and treatment. If this verification is not undertaken before hand, thenbilling errors, insurance coverage apprehensions and increased wait period occurs in both private and government-run insurance companies. As per the industry statistics, every one in four claims are generally deferred, denied or declined due to insurance eligibility verification issues.

This is one of the most crucial and important steps in the whole medical billing cycle. It is the first step and it is proven that more than half the claims that is not accepted or postponed is mostly due to ambiguity or furnishing of incorrect insurance coverage information. It is also because the insurance coverage information is not updated, changes in the coverage policy or the same have not been renewed by patients when they visit a medical practice for treatment or consultation.

Insurance verification process includes:

  • Getting the patient schedule

  • Checking the Insurance eligibility and coverage

  • If required, then patients are contacted

  • Billing system updation

Why is this process beneficial?

  • Insurance agencies or companies frequently change existing healthcare policies, update or make amendments to health coverage plans

  • This is the first step in the revenue cycle management process for all providers and aids both members and providers

  • Validate coverage and benefits details from the broad list of payors before actual services are rendered. If the patient’s health plan benefits are changed, is the coverage more beneficial or not can also be verified.

  • If patient information is to be substantiated, then submit the relevant patient coverage information and get the reply right away

  • There is a good synchronization of patient care and benefits as both of them have informed awareness.

  • Co-payments can be collected at the time of service rendered also claims are approved and accepted as soon as they are submitted because all the verification process is done and it is factual

  • Time- saving factor over individually verifying eligibility, telephonically

  • The flow of cash or co-pays collected ahead is increased

  • Lessen refusals or denials as non-verification can lead to rework or resending the claim and is grounds for more errors

  • Increases competence and your staffs output, augments cash inflow and better patient satisfaction ensured

There are two types of insurance eligibility verification, basic and advanced verifications:

  1. In the basic verification process, first of all the eligibility timeline is verified, both the coverage effective from and to dates. For this, general patient detail, name, address, contact information, insurance coverage information, claim filing limits, type of plans, any pre-existing conditions, whether the provider is in-network or out-of-network is sought and the same is entered into the relevant form for verification. Also the co-pay, co-insurance, dependent insurance and other deductibles are also verified. Verifying these details in the first quarter of the year is advisable, as that is the time when the insurance comes up for renewal and patients may or may not renew their insurance coverage. Also, if an organization is providing group health insurance benefits, the same should be verified, the benefits in the list of order should be primary, secondary and tertiary benefits.

  1. In the advanced verification process, all the aforesaid basic verification process is undertaken. In addition to that certain other details like the rate of renewal frequency, whether it is annual or a monthly renewal, health fund availability, maximum benefits coverage that is already used or met for the calendar year, pre- certification and authorization requirements, co-pays for lab service, tests, injections etc. any policy exclusions or limitations, specialty service-based information like for cardiology, physical therapy, general surgery etc. DME-related information and the ‘annual maximum’ or ‘lifetime maximum’ benefits limits are verified.

When enrolling the services of HealthPay Inc. for insurance eligibility verification, we categorize our services by:

Importance of insurance verification:

  • The revenue cycle wait is reduced significantly

  • Delays and denials are reduced noticeably

  • Cash flow and revenue improves because write-offs can be reduced

How do we verify?

  1. We receive patient schedules via EDI, email or fax and we check them on a daily basis with our relevant software.

  2. If need arises, patients are also contacted for any additional information.

  3. We check the patient’s coverage with both the primary and secondary payers and also checking and verifying online on the insurance portal.

  4. The medical billing system or the claim contains details like the Member ID, Group ID, coverage period, co-pay data and any other relevant information.

  5. In case of any issues, the client is immediately notified.

Our expertise:

  1. We are experts in all kinds of verifications

  2. We ensure an accurate and quick turnaround

  3. Vast information and knowhow about coverage types, benefits and payor plans

  4. Our experienced professionals, up-to-date infrastructure, information and data security are the added feathers in our cap

  5. All information is stored and protected electronically and aided by the best software

  6. Benefits for the client include reduced revenue cycle in billing, minimizing delays and denials, lesser fees and charges involved, we have a strong patient-focus and improved collections and revenue figures

 Ok, how do we begin?

You can send us a sample list of patients from the provider’s practice and we in turn will send you a free, no-obligation patient verified list to you. This will be undertaken after we have signed the necessary HIPAA compliance forms with you. If we can be a value-add to your practice, and then we could discuss further, sign a contract and embark on providing insurance verification services to you.

Work Flow

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