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Checking Patient Eligibility and Benefits

Checking Patient Eligibility and Benefits

Patient eligibility and benefits verification is the process by which medical practices confirm insurance coverage for planned care. This insurance coverage report will include information such as coverage, co-payments, deductibles, and coinsurance with a patient’s insurance company. Patient eligibility and benefits verification is an important process of Revenue Cycle Management (RCM), which comprises the steps practices must take to keep track of revenue and ensure they get paid. By verifying eligibility, practices determine patient insurance coverage prior to appointment and can cross-check any updates in demographic information. Proper eligibility and benefits verification will ensure a complete insurance coverage report prior to appointment, resulting in lesser denials and increased patient collections.

Checking Patient Eligibility and Benefits

Practices mostly use two different methods to verify eligibility i.e., electronic real-time eligibility checks and manual checking. You can use electronic real-time eligibility to run checks at least 48 hours before the patient’s appointment. Electronic real time eligibility may not be suitable option for small practices with lesser visits. Small practices manually check patient eligibility and benefits. Practices call the insurance rep and ensure insurance coverage details like patient’s insurance status and benefits; patient’s benefit plan; unpaid deductibles; co-payment; and dollar amount against tentative procedure codes. Practices also ensure patient demographics is updated along with information like primary care physician (PCP) and coordination of benefits (COB).

In case of a manual eligibility check, simply call the insurance company’s contact number listed on the back of the patient’s insurance card or log into the payer’s web portal. When you call insurance, information required will be subscriber name; patient name; patient’s relationship to the subscriber; patient date of birth (DOB); patient gender; patient member number; group name and number; and plan type coverage date. The insurance rep will ask and cross-check any of the patient’s demographic details and practice details to ensure that you are an authorized, person. Practices should proactively check eligibility. The most effective time is before the patient is seen by the physician, ideally 48 hours before the visit.

Best Practices for Eligibility and Benefits

To decrease denials and potential delays in revenue, follow these best practices prior to the visit:

  • Check for inactive plans and flag the accounts.
  • When patients have multiple insurance plans, remind them to update their COB with each payer. Check for primary, secondary, and tertiary insurance, note that Medicaid is always considered the payer of last resort.
  • For patients 65 or older, it is always best to verify whether their insurance coverage is ‘traditional’ Medicare coverage.
  • Confirm the services covered under the patient’s insurance policy and whether a referral or prior authorization is needed. Ensure referrals and authorizations are approved, entered in the system, and linked to the correct visits.
  • See if a benefit limit is listed, specifying how much of the benefit remains.
  • Some plans may have limitations for the dollar amount of each visit or the frequency and time frame in which the services must be delivered (e.g., a benefit limit of 12 visits, with a visit limit of two visits per month). Insurance plans may indicate that the provider should call customer service for psychiatric and substance abuse benefits information.
  • Determine the amount of a co-payment, coinsurance, and deductible amount.
  • Obtain as much demographic information as possible. Some demographic details (i.e., preferred language, sex, race, ethnicity, and date of birth) will affect Meaningful Use (MU) reporting.
  • Always ask if the patient has had a change in insurance, whether a new policy or change in coverage.

Strengthen Medical Billing with Trusted Billing Company

Manging eligibility and benefits verification is a challenging task. Checking patients’ insurance coverage before every patient visit is a must and will ensure accurate insurance reimbursement. It may not be possible for you to check benefits for every visit, as you are constantly busy in patient care. Managing eligibility and benefits verification can feel daunting, especially in addition to all the other critical RCM steps. But you don’t have to do it all yourself! When you partner with Medisys Data Solutions, you can benefit from specialty-specific billing expertise and a team dedicated to helping you achieve your revenue goals. We can handle complete medical billing for your practice and can ensure accurate insurance reimbursement for every claim. To know more about our complete medical billing and coding services, contact us at 302-261-9187

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