Why does Patient Eligibility and Benefits verification matters

One of the fundamental and most crucial task in the front office of any medical practice is to verify patient’s eligibility and benefits. In this process, the staff at medical facility gather details of patient upfront and also confirm their insurance coverage that can significantly impact the revenue cycle and patient’s satisfaction on your practice.

Why is Eligibility Verification Important?

Through the process of eligibility verification, it is ensured by the front desk that insurance plan of the patient is active and it is covering the required services. Verification before providing care can help reduce denials for a healthcare provider it also helps accelerate the payment cycles which ultimately improves the cash flow. The prior process of eligibility verification also enhance patient experience as it helps practices reduce and even avoid unexpected patient expenses.  

What Information Do Insurance Companies Need?

In order to effectively verify the insurance eligibility, there are certain key details that must be collected, which are as follows:

1. Subscriber information: The detailed information of the primary person insured under the policy, including names, membership number and necessary verification data.
2. Patient information: Name of the patient, their date of birth, gender and relationship with the primary subscriber of the insurance plan.
3. Policy details: this involves taking details about the type of plan, group number, coverage date and any inclusions or special conditions if mentioned in the policy plan.
4. Benefit details: this involves getting information regarding deductibles, co-pays, co-insurance, payable benefits, policy status and effective dates.
5. Other essentials: this includes the mailing address of claims, referrals requirements pre-authorizations, and any lifetime maximums.  

By conducting the above details accurately, we can ensure the smooth processing of claims and also that the patients are aware of their financial responsibilities upfront.

Methods of Eligibility Verification

To verify the patient eligibility there are two primary methods electronic and manual are used by the medical practices.

1. Electronic Verification: Most insurance companies offer online portals or interfaces to check eligibility in real-time. Verifying eligibility electronically before the patient’s appointment helps ensure you have accurate information about their insurance status and benefits. It allows you to:
• Confirm if co-pays need to be collected at the time of service.
• Update insurance details and verify the primary care physician.
• Reduce the likelihood of errors and improve claim acceptance rates.
2. Manual Verification: Sometimes, it’s necessary to call the insurance company directly. This may be required to clarify specific elements of coverage, such as prior authorization requirements or plan exclusions. It’s a more time-consuming process but essential for certain types of services or complex policies.

Timing is Key

To minimize claim denials and ensure a smooth billing process, eligibility should ideally be verified at least 48 hours before the patient's visit. If this isn’t possible, eligibility checks can be performed in real-time during patient check-in. Verifying insurance details promptly helps reduce claim rejections and ensures that patients are only billed for services covered by their insurance.

Customizing the Process for Your Practice

Every medical practice is unique, and eligibility verification processes should be tailored to meet specific needs. For example, a substance use support clinic will have different verification requirements compared to a hospital or a radiology clinic. Establishing specific workflows and documentation for eligibility and benefits verification ensures that all staff members understand their roles and responsibilities, reducing errors and improving efficiency.

Best Practices for Effective Eligibility Verification

Here are some best practices to follow for patient eligibility and benefits verification:

• Verify Plan Activity: Always check if the insurance plan is active before the appointment.
• Inquire About Changes: Ask patients about any recent changes to their insurance coverage to avoid surprises.
• Check for Multiple Insurances: If the patient has multiple insurances, ensure that the Coordination of Benefits (COB) is updated with each payer.
• Confirm Coverage for Services: Verify whether the patient’s policy covers the planned procedure or service.
• Understand Limitations: Some insurance plans limit the number of visits or the timeframe for services. It’s essential to know these details to avoid denials.
• Collect Payments Upfront: Based on the policy details, collect deductibles, co-pays, and co-insurances at the time of service to minimize the need for patient collections later.

The Role of Social Determinants in Eligibility Verification

Social determinants of health, such as race, gender, ethnicity, and preferred language, are becoming increasingly important in healthcare delivery. These factors not only contribute to equitable care but are also crucial for reporting and studies on health equity. Including these details in your eligibility verification process helps support compliance and meaningful use reporting requirements.

Benefits of Outsourcing Eligibility and Benefits Verification

Outsourcing the eligibility and benefits verification process to a specialized service provider like eServMD can bring several benefits:

• Reduced Workload: Free up your staff to focus on enhancing the patient experience and other critical functions.
• Improved Efficiency: Speed up the time to care delivery by ensuring all verification tasks are completed promptly.
• Lower Denial Rates: Decrease the number of denials due to eligibility issues, leading to a smoother revenue cycle.
• Cost Savings: Reduce overhead costs through labor rate arbitrage and streamlined processes.
• Expert Handling: Benefit from well-trained professionals who specialize in eligibility and benefits verification, reducing errors and improving compliance.

Why choose eServMD for Your Eligibility and Benefits Verification Needs?

At eServMD, we understand that efficient eligibility and benefits verification is vital to your practice's financial health. Our experienced revenue cycle management team provides comprehensive solutions tailored to your practice's unique needs. By partnering with us, you can reduce costs, minimize denials, and improve overall operational efficiency. Request a free demo now.