Eligibility and benefits verification is the first and most significant step in the medical billing and coding process. Today’s continually changing and increasingly complex healthcare environment requires, more than ever, close attention to validating coverage, benefits, co-payments, and unpaid deductibles. With the eligibility and benefits verification process in place, you can collect more accurately. Thus, it becomes crucial that providers understand the insurance verification process and its importance in the healthcare industry.
Completing eligibility and benefits verification prior to appointment, for procedures or equipment, results in fewer claims being denied. Since insurance information change frequently, failure to stay ahead of ever-changing regulatory requirements could lead to rejected claims, billing errors, and reimbursement delays. Accurate insurance verification ensures a higher number of clean claims which speeds up approval and results in a faster billing cycle. Inadequate verification of eligibility and plan-specific benefits puts healthcare organizations at risk for claim rejections, denials, and bad debt. It is important to contact the patient’s insurance carrier prior to the procedure or services being rendered and ensure that it is included in the patient’s health insurance coverage. Errors in carrying out efficient insurance verification or submitting a claim for a procedure that the patient’s insurance carrier does not cover, or is delivered by providers who are outside the employee’s health insurance provider network, will leave the patient financially exposed, fearful, and frustrated. As a result, the patient will have to pay 100 percent for the services.
Impact of Eligibility and Benefits Verification on Patient Payments
- Verifying the patient’s insurance coverage in advance allows the practice to estimate the total patient responsibility for payment. This patient responsibility includes co-payments, unpaid deductibles, and co-insurances. When patients are informed of their responsibility prior to appointments, they’re far more likely to come to the appointment prepared to pay or make payment plans.
- Insurance coverage information can be confusing and is changing rapidly. Most of the time, patients are incorrect about their coverage. Many times, they aren’t aware that their deductibles have changed or other aspects that will impact the amount of money they need to pay out of pocket is different.
- A great way to collect more is to inform patients as soon as possible so that they can budget the extra costs or work with the practice to create a schedule of payment. With advanced communication about patient responsibility, they can make more informed decisions and trust your services due to transparency.
- Most patients want to pay their bills on time. Patient eligibility and benefits verification allows practices to help patients get all of the information they need so that they’re not blindsided by large bills. Verifying eligibility in advance protects practices in cases where insurance has lapsed or policies don’t cover the services.
Impact on Insurance Payments
- The physician, whether a primary care doctor or a specialist, needs to know if the insurance company considers them an in-network or out-of-network provider. The benefits generally differ between the two. Providers seeing Medicare patients definitely need to check with the carrier before seeing the patient. Coverage with a Medicare Managed Care Plan can easily confuse patients. Some Medicare patients will tell you that they have Medicare and show you their Medicare ID cards, not realizing that they enrolled in a Medicare Managed Care Plan.
- With eligibility and benefits verification, you can check their coverage regardless of the plan while a patient is in your office to avoid time-consuming claim payment delays from incorrect information. For new patients, collect and verify insurance information when they make an appointment. This gives your office staff time to check the information in advance. If possible, let the patient know what they’re expected to pay to avoid any unhappy surprises. We suggest undergoing benefits verification for every visit, even for established patients. Many factors go into figuring out the patient’s financial responsibility. Whether or not the provider is in-network, the type of provider and patient deductibles are just a few of these considerations.
You can perform eligibility checks several different ways, depending on the processes your office and insurance carrier use. You can verify patient information by checking the website of the insurance carrier or by calling a representative directly. Some practice management software and clearinghouses also can check patient eligibility for you, saving staff time and effort. A primary care provider generally wants to confirm that insurance is in effect at the time of service and figure outpatient responsibility portion. A specialist, however, needs to check if the co-pay for a specialist visit differs from the co-pay for a primary care visit. A specialist also needs to verify if their services will need a referral or pre-authorization.
MedicalBillersandCoders (MBC) provides prior authorization, eligibility, and benefits verification services. We confirm eligibility and benefits, which improves patient experience, and improves collections. We confirm the patient’s eligibility and obtain necessary prior authorization before the patient visits the physician’s office. To know more about our prior authorization, eligibility, and benefits verification services, contact us at email@example.com / 888-357-3226