Healthcare professionals play a key role in the patient eligibility verification process. Accurate verification of insurance coverage is crucial to a medical practice’s financial stability. Ensuring that every detail is meticulously verified can be a challenging task. Adhering to best practices in the insurance eligibility verification process will allow you to navigate this complex landscape with precision.
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Guidelines to Streamline Medical Insurance Verification
Establish Robust Verification Protocols
The process of health insurance verification 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 gathering and validating patient information, insurance particulars, and eligibility for coverage.
By proactively addressing various aspects before the patients visit, physician practices can significantly reduce the likelihood of encountering issues later on. Among these preparatory measures, eligibility checks play a crucial role. This involves reaching out to the patient insurance company, verifying deductibles, assessing coverage, and other related tasks.
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 as they constitute a substantial portion of their revenue. Failing to negotiate with payers or lacking 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 to insurance companies. It’s essential to understand and adhere to the specific requirements and guidelines set by your carriers for billing and reimbursement purposes.
In certain situations, a physician might provide multiple office or outpatient E/M (Evaluation and Management) services to a patient on the same day. “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.
Although 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,” Natalie says.
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 procedure. This includes demographic information, details on the insurance policy, primary and secondary insurance information, any pertinent authorizations or referrals, and the completion of consent forms. Health insurance verification specialists utilize user-friendly digital patient intake forms, increasing data accuracy and reduce 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 Clinical Documentation
It is the responsibility of healthcare professionals to maintain clear and accurate medical records, including meticulous documentation of patients’ conditions, diagnoses, treatments, and procedures. Medical records play a crucial role as vital evidence for insurance claims. Clear and detailed documentation helps insurance companies understand the medical necessity of the services rendered and validates the claims made by your practice. Ensure that the patient’s condition and the medical services rendered are accurately represented using the appropriate ICD-10 and CPT codes.
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 insurance 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 reduces wait times and enhances 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.
Outsource Patient Eligibility Verification
Investing in ongoing training programs for your staff to keep them up-to-date of the latest changes in insurance policies and procedures is crucial. This can be expensive. Utilizing insurance verification and authorization services is a more practical approach. Medical billing companies providing these services are well-equipped to handle diverse insurance scenarios and industry updates. They audit on the back end to ensure accuracy.
Their skilled team contacts insurance companies to gather essential billing details, including policy status, effective dates, co-payments, deductibles, and prior authorizations. By utilizing payer portals, they quickly retrieve necessary information online. In instances where immediate or complex information is unavailable, specialists proactively follow up with payers to resolve any outstanding issues. By navigating the complexities of insurance verification, experts can ensure a smoother billing process and improved financial outcomes for your practice.
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