25 Oct Medical Insurance Eligibility Verification: A Complete Guide
It’s no secret that healthcare can get expensive. As a result, nearly 90% of Americans rely on health insurance plans to make their care more affordable.
Medical eligibility verification (also called insurance eligibility verification) is an essential function of medical billing. Since insurance reimbursements play such a vital role in the revenue cycle, your practice must vet patients’ eligibility with care. This verification process enables prompt payments for your providers and financial transparency for your patients.
In this guide, we’ll share everything you need to know about medical eligibility verification and how to manage it the right way.
What is Insurance Eligibility Verification?
Insurance eligibility verification is the process of confirming a patient’s insurance plan before rendering services. It involves checking their coverage limits, copayments, deductibles, pre-authorization requirements, and other insurance details.
The three main methods for conducting medical eligibility verifications include:
- Calling their insurance provider – You can manually verify a patient’s health plan by calling their insurance provider. While this method may be necessary for more complex cases, it’s the most time-consuming of the three. That’s because insurance representatives can be hard to get a hold of over the phone.
Many insurers’ phone lines have long wait times and complicated menu options. Additionally, you may need to speak to supervisors to get answers to more complex questions, increasing your time on hold.
- Logging into the insurer’s online portal – These days, many insurance providers have online portals where you can virtually review patients’ data. Since this method doesn’t require you to connect with a representative, it can be more efficient than phone verifications. The only downside is that managing multiple portals can get complicated, particularly if you work with a large number of insurance providers.
- Leveraging automated insurance verification software – For the most efficient verifications, automated insurance verification software is a must. These systems match patients’ data to their insurance providers’ information and automatically alert you of any discrepancies or changes. In turn, they can streamline your workload, reduce errors, and shorten your verification times from hours to minutes. Best of all, you only need one login to verify data from various providers.
Why Is Insurance Eligibility Verification Important?
Insurance eligibility verification is a vital component of revenue cycle management (RCM). In particular, it can help your medical or dental practice:
- Reduce claim denials and rejections – Claim denials and rejections can disrupt the revenue cycle by delaying payments and stalling collections. Unfortunately, insurance claim denials are on the rise due to registration and eligibility issues. By verifying coverage before providing the services, you can collect copayments upfront and avoid claim-related complications.
- Enhance billing accuracy and cash flow – Medical and dental practice profit margins are already slim, so you want to do everything in your power to protect your cash flow. Insurance eligibility verification can help you obtain faster reimbursements, leading to a healthier cash flow and more accurate medical billing.
- Streamline your administrative workload – Following up on claim denials can take a lot of time. By reducing the number of claim denials and rejections your practice has to deal with, medical eligibility verifications can free up your administrators’ time to focus on other tasks, such as providing excellent customer service.
- Improve your patient’s satisfaction – Patients who receive surprise bills from your practice are less likely to offer positive reviews, repeat business, or referrals. By verifying patients’ coverage limits ahead of time, you can explain their out-of-pocket responsibilities before their appointment. This financial transparency can ultimately reduce stress and enhance patient trust and satisfaction.
How Does Insurance Eligibility Verification Work?
Insurance eligibility verification is a straightforward process that can be broken down into three steps:
#1 Collect Patient Information
Before you can verify a patient’s insurance eligibility, you need to ask for their information, including their:
- Name
- Gender
- Date of birth
- Insurance provider
- Policy number
- Plan type (HMO, PPO, etc.)
- Subscriber name
- Relationship to subscriber
- Group name and number
- Policy effective date
Ideally, you should gather this information at least 48 hours before the patient’s scheduled appointment. This way, you have ample time to complete the verification.
Once your patient arrives at the office, take a copy of their insurance card for your records.
#2 Confirm Coverage Details
Once you’ve collected information from your patient, you need to verify it with their insurer. Start by seeing if your practice is within their insurer’s network. After that, you can use one of the three verification methods we discussed above to compare their data with their insurer’s information.
When you do, make sure to carefully review their:
- Copayment
- Deductible
- Pre-authorization requirements
- Special clauses that could limit coverage
This information can help you clarify your patient’s coverage, estimate your insurance reimbursement, and calculate the patient’s remaining balance.
#3 Document and Share Your Verification Results
Once you’ve verified your patient’s eligibility and coverage, make sure to record your findings in their file. Documenting these details can help you track changes to their policy over time and make billing decisions on the most up-to-date information.
An automated insurance verification system will complete this documentation process for you. These systems automatically store and update patient insurance information in real time, ensuring that your records are always current and easily accessible.
Next, make sure to communicate your findings to your patients. Let them know exactly how much they’ll owe upfront and explain any other potential out-of-pocket expenses.
3 Common Medical Eligibility Verification Challenges
While having a standardized, step-by-step process can streamline your verifications considerably, you may still experience some challenges along the way. Some of the most common challenges include:
- Changes to insurance coverage or policy updates – Patients may submit outdated information by mistake or fail to report changes to their coverage. In these situations, you may incorrectly conclude that they lack sufficient coverage, leading you to quote them higher out-of-pocket expenses.
- Lack of standardization across insurance providers – In the United States, consumers can choose from over 1,100 different insurance providers. Each of these providers has its own policies, making it difficult to enact standardized verification processes without automated insurance verification software.
- Time-consuming manual processes – Whether you complete them over the phone or within a provider’s online portal, manual insurance verifications can take a lot of time.
The good news? By following the best practices below, you can prevent many of these challenges.
4 Best Practices for Effective Insurance Eligibility Verification
Create an efficient, accurate verification process by following these best practices:
- Use electronic verification software – In 2024, there’s no reason to conduct your insurance eligibility verification manually—automated tools are widely available. These tools can save you time, improve claim submission accuracy, and relieve your administrative workload.
- Train your staff on your preferred verification protocols – Having standardized verification protocols in place won’t do much good unless your staff follows them properly. Thus, it’s important to train your staff on your preferred protocols and software solutions.
- Maintain up-to-date patient insurance records – Next, you can refine your patient eligibility verifications by updating and verifying their data every time they schedule an appointment. After all, you never know when an existing patient may have altered their coverage or switched providers.
- Prioritize patient communication – Lastly, you should make patient communication a top priority. Clearly explain your patient’s coverage details and out-of-pocket expenses to them before their appointment so they know what to expect.
Want to learn more ways to decrease claim rejections and denials? We explore that subject in greater detail in our comprehensive guide, How to Reduce Eligibility Rejections and Denials.
How Automation and Technology Can Improve Eligibility Verification
Automated technology can transform your verification process. For example, Medusind’s proprietary QuickVerify™ technology can help you save time, craft ideal treatment plans, and increase your clean claims rate.
This convenient and fully automated solution requires very little training to implement. Better yet, our staff will make sure that all of your QuickVerify data automatically populates into your chosen Practice Management System.
Thanks to these benefits, your administrative staff can spend more time focusing on patients and less time on hold with insurers. As a result, this tool can improve the experience for your administrative staff and patients alike.
Elevate Your Medical Insurance Eligibility Verification Process With Medusind
Medical eligibility verification is a vital step in RCM. If you want to optimize this area of your medical or dental practice, Medusind can help. As an experienced medical billing company, we have over 20 years of experience supporting sole proprietor dentists, small group practices, and large DSOs.
By partnering with us, you can gain access to our QuickVerify™ technology, along with our expansive staff of well-trained and knowledgeable RCM professionals. We’ll help you complete verifications on time, every time, with an unparalleled high level of accuracy.
Ready to learn more about our RCM solutions? Schedule a call with our team today.
