Verifying patient health insurance is a crucial yet complex process in healthcare. With a growing range of public and private insurance options, as well as ever-changing coverage plans, insurance validation is a challenge.
This practical guide presents essential steps, best practices, and solutions to help healthcare organizations reliably confirm their patients’ insurance coverage.
Importance of Health Insurance Verification
Health insurance verification is critically important to healthcare providers, with recent surveys showing that 30% of medical claims submitted face denials or requests for additional information for a variety of reasons, including failing eligibility checks. Beyond claim denials, inaccurate verification also increases the time spent on follow-ups.
Preventing revenue loss due to claim denials
Submitting claims for an inactive policy or for uncovered services risks denial and reimbursement delays. Verifying eligibility with automated insurance verification helps avoid unnecessary financial losses that can affect revenue.
Avoid unexpected patient billing
Obtaining accurate coverage details before providing service allows for informed patient advice regarding potential charges. This proactive approach reduces the risk of surprise billing, thereby improving overall patient satisfaction.
Reduce administrative follow-ups
Incomplete verification often requires extensive follow-up efforts to coordinate benefits, update expired policies, and resubmit denied claims. Accurate initial confirmation significantly reduces this administrative work.
With the “why” clear, let’s explore best practices for accurate patient insurance verification.
Optimizing the verification process
Focus on four core principles:
Use automation where possible
Automated eligibility verification and coverage change tracking can significantly reduce manual work while improving data accuracy.
Integrate with existing software
Insurance validation must align seamlessly with existing EHR and billing software. When software is integrated effectively, staff can easily confirm eligibility as part of standard procedures.
Define staff responsibility
Ensure verification roles and responsibilities are clearly defined among admissions staff, schedulers, billers, and other staff. Once ownership is established, accurate confirmation remains an ongoing priority.
Monitor and improve
Continually review the verification process to identify areas for improvement, gather feedback from your admissions and billing staff.
With these principles in mind when developing assurance verification processes, let’s explore the standard confirmation steps.
Key Steps to Verify Patient Insurance Coverage
Confirming eligibility and plan details involves a set of basic steps at different points during the patient engagement. This section outlines the verification process in general. If you need more details, please follow the link: https://approvedadmissions.com/how-to-verify-patient-insurance-eligibility-and-benefits/.
1. Collect patient data upon admission
The first coverage check usually takes place when the patient is admitted.
Key details to collect:
Beneficiary Name, Date of Birth, Contract ID Insurance Company and Group Plan Name Plan Type – Medicaid, Medicare, or Private Commercial Insurance
Also check if the patient has secondary insurance. Quickly verify eligibility and coverage plan details using automated verification software. Make sure the tool checks current eligibility status and coverage limits, as well as any exclusions or restrictions.
Be sure to keep the verification documents received.
3. Estimate the patient’s expected responsibility
Once verified, assess coverage levels and deductible status to estimate patient out-of-pocket costs for the healthcare services discussed. Confirm any prepayments or copayments required for the scheduled visit and inform the patient about potential balance billing for coinsurance so they understand financial expectations.
4. Regularly monitor changes in insurance coverage
Given the potential for rapid changes in insurance enrollment, it is essential to recheck eligibility regularly throughout a patient’s stay, particularly the day before any scheduled service or surgery.
Automated verification software can provide automatic notifications of any changes in coverage status, ensuring timely updates without additional manual work.
Medicare and Medicaid Coverage
Medicare: Check the patient’s enrollment in Medicare Part A (hospital insurance) and Part B (outpatient insurance). Check if they are enrolled in a Medicare Advantage plan (Part C) or Medicare prescription drug coverage (Part D).
Medical Assistance: Medicaid benefits and coverage rules can vary widely from state to state, so the specifics of coverage and coordination may differ depending on where a patient lives.
Some patients may be dually eligible for Medicare and Medicaid. Keep in mind that Medicare will typically pay for services first, while Medicaid may cover some or all of the remaining costs.
States have programs in place to coordinate benefits for dual-eligible patients, ensuring that they receive appropriate coverage and that providers are properly reimbursed.
Key points to remember
Ensuring patient insurance details are accurate helps protect your practice from unpaid claims. Consider implementing automated eligibility checks to reduce billing errors and avoid denied reimbursements.
Proactive insurance verification improves efficiency and streamlines your revenue cycle.
Originally published in The European Times.
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