The process by which hospitals confirm information, including coverage, copayments, deductibles, and coinsurance, with a patient’s insurance carrier is known as patient eligibility and benefits verification. It’s a crucial part of revenue cycle management (RCM), which includes the measures companies must take to keep track of income and get paid.
Practices can determine the status of a patient’s medical insurance coverage before the appointment and accurately report demographic information on insurance claims by verifying eligibility,
Moreover, prioritizing eligibility supports proactive patient collection measures and avoids payment delays. Disregarding checking eligibility is a common cause for medical claim denials.
Want to avoid denials and increase your practice’s clean claim rate? Read on for answers to your questions regarding eligibility.
How does a practice check eligibility?
Practices can use two methods to verify patient eligibility: electronic real-time eligibility checks or manual checking. It is a best practice to use real-time electronic eligibility to run checks at two days before the patient’s appointment.
This method allows you to:
- Gain enabled the patient’s insurance status and benefits before the visit.
- Request updates from the patient and advises if a copay is due at the time of service.
- Verify insurance updates and ensure the account is highlighted for expedited check-in.
- Ask patients to update their primary care physician (PCP) and coordinate benefits (COB).
While it is less efficient, manually checking eligibility may be important to ask the insurance company specific questions regarding the patient’s benefit plan. Call the insurance company’s contact number on the back of the patient’s insurance card or log into the payer’s web portal.
What is the eligibility coverage information provided?
For every patient, the following information is required:
- Subscriber name
- Patient name
- Patient’s relationship to the subscriber
- Patient’s DOB
- Patient’s Sex
- Patient member number
- Group name and number
- Plan type coverage date (policy effective date)
Beyond that list, payers may be asked to share extra information if available in the health plan’s records and suitable for the coverage. This could include other insurance coverage in effect, PCP, and eligibility status. The correctness of this material, however, cannot be guaranteed.
The right time to check the eligibility
Practices should assess eligibility regularly. Before the physician sees the patient, the most productive time is 48 hours before the visit. Alternatively, this procedure can be carried out at any time before or during check-in. Patients should always be asked if their insurance has changed since their last appointment.
Advice: Keep a recent copy of the patient insurance card(s) on file for reference during the billing process. Back-office billers may demand to verify eligibility while working on rejected and denied claims.