Verification of patients’ insurance coverage is a crucial step in the medical billing process. It involves confirming the patient’s benefits and eligibility prior to delivering medical services or treatments. Verification of patient benefits helps determine the extent of the patient’s coverage and their financial responsibility. Accurate health insurance eligibility verification helps prevent unexpected costs for both the patient and the healthcare provider.
Optimize your revenue cycle with our reliable insurance eligibility verification services!
Patient eligibility issues are one of the common reasons for rejected or denied claims. The cost to rework or appeal denials averages $25 per claim for practices and an exorbitant amount of $181 per claim for hospitals (MGMA), which can significantly impact the provider’s financial stability as well as patient satisfaction. However, ensuring proper verification of patient benefits can be a challenging task. Adhering to best practices in the patient eligibility verification process is essential to navigate this complex landscape with precision.
Strategies to Streamline Medical Insurance Verification
Establish Robust Verification Protocols
Verification of patient benefits consists of several steps, covering meticulous data collection and confirming coverage through interactions with insurance providers and patients. Start by implementing standardized protocols and develop a comprehensive checklist for conducting verifications. This checklist should have detailed instructions for collecting comprehensive patient information during registration, contacting the insurance provider to verify policy status and coverage details, checking for required pre-authorizations, documenting verification results, and regularly updating patient information to ensure accuracy. All front desk staff should receive proper training on the steps, and understand their responsibilities and timelines involved in the verification process. This will ensure consistency and reduce the likelihood of errors.
Understand Payer Contracts
Physicians should thoroughly evaluate and understand payer contracts. The contract with the payer outlines the terms of reimbursement for medical services provided to patients covered by that insurance plan. It includes details like allowed charges, covered services, and specific billing codes, basically establishing how much the provider will be paid for each service rendered to a patient with that insurance plan. Lack of a comprehensive understanding of insurance contracts can have serious financial consequences for your practice.
Each year, provide your carriers with a comprehensive list of the most commonly performed services in your practice. This will allow them to supply a fee schedule specifically tailored to these services, simplifying the negotiation process. By examining the average allowables for all insurances for your most frequently provided services, you can assess how each payer’s rates compare to Medicare and other commercial insurances. If a commercial payer is reimbursing you at a lower rate than Medicare, it may be worth considering initiating contract negotiations with that payer. Additionally, it would be beneficial to gather information on the reimbursement rates of other in-network providers in your local area across different healthcare settings to evaluate how your rates compare to theirs.
Know Payer Billing Policies
Payer billing policies come into play when submitting claims for reimbursement. It’s essential to understand and adhere to the specific billing requirements and guidelines set by the carriers. “It’s important to understand what services you can bill and get paid for same day for same/different providers in the office,” says Natalie Tornese CPC, OSI’s Director of Revenue Cycle Management, Healthcare Division.
A physician might provide multiple office or outpatient E/M (Evaluation and Management) services to a patient on the same day. Although “new patient” E/M codes 99202-99205 and “established patient” E/M codes 99211-99215 do not explicitly mention “per day,” it’s important to note that payer regulations may restrict the reporting of more than one E/M code for a single patient on the same date of service. For instance, the Medicare Claims Processing Manual, chapter 12, section 30.6.7.B states that Medicare will not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day. But there is an exception to the rule: Medicare allows reporting separate E/M codes for the same date if the provider documents that the visits were for unrelated problems and that the services could not be provided during the same encounter.
“For multi-specialty practices with more than one provider on site, our teams have experience with checking coverages for services that are categorized according to the appropriate provider/NPI to ensure those services get paid correctly,” says Natalie.
Practices should regularly monitor and stay informed about changes in payer policies. Staying ahead of policy adjustments and billing rules ensures that your verification processes aligns with the latest requirements, reducing claim rejections.
Perform Comprehensive Eligibility Checks
To begin the insurance verification process, gather thorough and precise patient information during the registration or intake process. This includes demographic information, details on the insurance policy, primary and secondary insurance information, any pertinent authorizations or referrals, and completed consent forms. Health insurance verification specialists utilize user-friendly digital patient intake forms, increasing data accuracy and reducing processing time. This ensures that accurate patient information is entered into the system, facilitating seamless verification and streamlined claims processing.
Keep in mind that rechecking eligibility before services are provided is just as important as the initial check. Verifying and updating patient details regularly prevents discrepancies that could lead to claim denials. Rechecking eligibility before submitting claims is vital to confirm that the patient’s insurance coverage is still valid and applicable to the specific procedures or services being rendered. Taking any changes in insurance coverage or policy limitations into account before submitting claims reduces the risk of denials and the need for subsequent appeals or financial disputes.
Ensure Thorough Documentation
After verification of patient benefits, document the information, including any limitations, for future reference. Thorough documentation during insurance verification is critical for ensuring a smooth claims process and minimizing the risk of denials or delays. Document demographics, insurance details, primary and secondary insurance, authorization and referral requirements, details of services that need preapproval, copies of signed consent for treatment and authorization, and date and time stamps
Maintaining comprehensive records ensure that all required information is available for claim submission. It reduces risk of billing errors, facilitates seamless communication between the healthcare provider, the patient, and the insurer, and supports meeting compliance standards.
Adopt a Patient-Centric Approach
A patient-centric approach is of utmost importance in insurance checks due to its impact on the overall patient experience and healthcare outcomes. Providing secure online portals or mobile apps for patients to conveniently enter their insurance information can streamline the eligibility verification process. This reduces the need for repetitive data collection during in-person visits and improves efficiency. Providing patients with a portal where insurance cards can be uploaded and forms completed digitally will cut wait times and enhance patient satisfaction. Clear communication is crucial. Provide patients with detailed information about the insurance verification process, using simple language and avoiding confusing jargon. Create step-by-step guides and resources, such as brochures or online materials that explain common terms and answer frequently asked questions. This enables patients to understand their role in the process.
Investing in ongoing training programs for your staff is essential to keep them up-to-date of the latest changes in insurance policies and procedures is crucial. However, this can be expensive. Outsourcing is a practical option to ensure accurate and timely verification for quicker claim submissions and payments.
Outsource Verification of Patient Benefits
Utilizing insurance verification and authorization services enables healthcare providers to reduce their administrative burden and focus on patient care while ensuring efficient billing and revenue cycle management. Medical billing companies providing these services are well-equipped to handle diverse insurance scenarios and audit on the back end to ensure accuracy.
Their skilled team utilize payer portals and even contact insurance companies directly to quickly confirm details such as policy status, effective dates, co-payments, deductibles, and insurance prior authorization requirements. In instances where immediate or complex information is unavailable, specialists proactively follow up with payers to resolve any outstanding issues.
By expertly navigating the complexities of insurance verification, professionals can ensure a smoother billing process, better financial outcomes for your practice, and an enhanced patient experience.
Ensure smooth claims processing with expert Insurance verification.
More from This Author
