Eligibility Verification: Most Neglected Process of RCM

What is Eligibility and Benefits Verification?

To receive payments for the services rendered, healthcare providers need to verify each patient’s eligibility and benefits before the patient’s visit. According to RemitData, two of the top five claim denial reasons for the year 2013 were insurance-coverage related. With more patients choosing high deductibles plans, this figure might have increased significantly in recent times. In spite of that, eligibility and benefits verification is considered to be the most neglected process of RCM. Ineffective eligibility and benefits verification process can result in increased claim denials, delayed payments, additional effort on rework, delays in patient access to care, decreased patient satisfaction, and non-payment of claims. In this blog, we shared the benefits of the eligibility verification process and also briefly discussed the eligibility verification process. 

Benefits of Eligibility Verification

  • Clean claim submission: The accurate eligibility verification process helps to submit clean claims and reduces efforts to re-submit claims. Clean claim submissions also ensure quicker payments. 
  • Reduce claim denials: As eligibility and benefits are verified upfront, the insurance, and patient portion will cover the procedures with fewer chances of claims getting denied.
  • Reduce write-offs: Upfront determination of patient responsibility for payments reduces patient debts. 
  • Increased patient satisfaction: With eligibility verification, patients are well informed about their insurance coverage and out-of-pocket portion. As patients are well informed and not receiving any un-informed invoices, this increases patient satisfaction. 
  • Increased practice collections: Eligibility verification helps practices to increase collections through a reduction in claim denials, decreased in write-offs, and improved patient care.

Eligibility and Benefits Verification Process

Even though the eligibility and benefits verification process are crucial, most practice owners don’t have sufficient time and/or skilled manpower to conduct this process. For reference we shared how we conduct eligibility verification for our clients:

  • We receive a patient schedule from the provider’s office or clinic. The provider will share a copy of the patient’s insurance card/s (primary and secondary insurance).
  • Error-free entry of patient demographic information in provider’s software.
  • Verify coverage of benefits with the patient’s primary and secondary payers. We verify details like Effective date and coverage details; Individual patient eligibility; Type of plan, Payable benefits; non-covered procedures; Co-pay; Deductibles; Co-insurance; Claims mailing address; Referrals; Pre-existing clause; Max-daily benefits; Lifetime maximum; and Other related information. We also check whether a referral, pre-authorization certificate of medical necessity is required for payment.
  • We take extra care when transcribing information into the patient record. The information builds the foundation of the medical claim.
  • If there are any questions or concerns regarding patient responsibility, we request the provider’s office to follow up with the patient about correct/alternate insurance information. We verify benefits for all provided insurances.
  • Where required, the team will initiate prior authorization requests and obtain approval for the treatment. Prior authorization is very important in revenue cycle management (RCM) as payers need to confirm whether a particular medication or procedure will be approved. 

If you don’t have the required expertise or the skilled manpower to handle eligibility verification, no need to worry. We offer eligibility verification services as part of full revenue cycle management services or as a separate service. We provide customized eligibility verification services as per the requirements of your practice. We provide basic insurance eligibility verification services that provide coverage details of the patient in addition to the co-pays and deductibles applicable. In-depth eligibility verification service includes gathering of ‘code specific’ eligibility with annual max or lifetime limits and prior authorizations when required. To know more about our eligibility and benefits verification services, contact us at info@medicalbillersandcoders.com/ 888-357-3226