Checking Patient Eligibility While Medical Billing to Ensure Future Payments


HIPAA Compliance and HIPAA GuidelinesMedical billing forms the backbone of healthcare revenue and profitability and is as crucial a process for care providers as are medical procedures. With government regulations becoming increasingly stringent and complicated coding and billing guidelines getting introduced every year, medical practitioners are facing dwindling revenues despite heavy inflow of patients. Clearly, the gap in service and payout is being created and widened at the point of billing. To ensure regular payments for medical services rendered, it is important that care providers start checking patient eligibility for medical transactions.

Checking patient eligibility during medical billing companies process comprises of the following steps –

Patient responsibility – pre billing > Documentation check > Insurance coverage check > Pre-authorization and referrals > Claim, deductibles & reimbursement
  • Patient responsibility and pre-billing – Informing the patient at the first point of contact about diagnostic and patient care requirements facilitates both the care provider and patient. A more informed patient can participate in the eligibility check more effectively and generate value adding medical record.
  • Documentation Check – Confirming the availability of required documents pertaining to date of birth, address, SS number, etc. is very important for ensuring that patient is eligible for service providing and also to ensure future claim settlement.
  • Insurance coverage- With Medicare and Medicaid extending coverage to millions more by 2014 and private insurance carriers emulating government carriers for offering insurance; patient eligibility depends heavily on insurance coverage. Selective healthcare coverage pertaining to health conditions and diseases makes scrutiny at the time of patient walk-in absolutely necessary.
  • Pre-authorization requirement – Many insurance carriers require pre-authorization for later claim settlement. Ensuring correct coverage at the pre-authorization stage confirms patient eligibility and facilitates the claim settlement process. In addition to pre-uthorization, checking referrals attached to every patient is also very crucial.
  • Claims, deductibles and reimbursement rate – Claim filing is a process which doesn’t begin after the service delivery, but way before that. In order to ensure that the claim is filed with proper documents and claim settlement time as well as ratio is suitable for the financial viability of the clinic; it is essential that patient eligibility is confirmed in the beginning. Many insurance carriers have some deductibles and varied reimbursement rates worked into their coverage conditions which must be addressed at the time of patient walk in, otherwise your practice may face unwanted financial surprises at the time of settlement. is a medical billing service provider that not only carries out a robust patient eligibility check but also ensures that your medical billing process satisfies the following two criterion –

  • HIPAA compliance – With ICD-10 medical codes and coding practices getting revised at frequent intervals, updating coding database of the billing systems becomes crucial. As most of the practices are adopting EMR for medical billing, HIPAA compliance check has to be ensured at various interfaces wherein patient data is recorded or transferred.
  • Frequency of eligibility checks – Lastly, installing various eligibility procedures in the system is not enough if the process is not followed at regular intervals. High frequency of eligibility checks ensure that the practice doesn’t serve any non paying patients and attract inadvertent losses in future.

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