Eligibility and verification are critical components of revenue cycle management for medical group practices. Ensuring that patients are eligible for services before their visit not only improves operational efficiency but also minimizes revenue losses from claim denials. However, many practices face challenges in effectively verifying eligibility due to outdated processes, insufficient information, or lack of standardization.
Accurately determining patient eligibility before their visit helps streamline the check-in process, reduces the risk of claim denials, and improves overall operational efficiency. However, many practices struggle with outdated or inefficient verification processes, which can lead to delays in reimbursements and missed revenue opportunities.
1.How does a practice determine whether or not a patient is eligible?
To validate eligibility, practices can utilize either computerized real-time eligibility checks or manual checks. Using electronic real-time eligibility to perform checks at least 48 hours before the patient’s visit is recommended.
- Gain access to the patient’s insurance status and benefits prior to the visit using this way.
- Get updates from the patient and let them know if there is a copay needed at the time of treatment.
- Verify that your insurance is up to current and that your account is marked for a speedy check-in.
- Request that individuals update their primary care physician (PCP) and benefit coordination (COB).
Manually assessing eligibility may be necessary to ask the insurance company specific questions about the patient’s benefit plan, which is less efficient. Simply dial the phone number on the back of the patient’s insurance card or visit the payer’s website.
2. What information to provided during an eligibility verification?
Every patient should be given the following information:
- Subscriber’s name
- Patient’s name
- Patient’s relationship to the subscriber
- Patient’s date of birth
- Patient’s gender
- Patient’s member number
- Group number and name (policy effective date)
Additional information may be sent if it is accessible in the health plan’s database and is relevant to the coverage. Other insurance coverage may be in force, as well as PCP and qualifying status. This information’s correctness, however, cannot be guaranteed.
3.When should you verify patient eligibility?
Practices should confirm eligibility ahead of time. The best time is before the patient sees the doctor, ideally 48 hours before the appointment. Alternatively, this procedure can be completed at any time before or during check-in. If a patient’s insurance has changed since their last appointment, front-office employees should always inquire.
Keep a current, legible copy of the patient’s insurance card(s) on file to refer to during the billing process, since back-office billers may need to confirm eligibility when handling rejected or declined claims.
4.What are the best techniques for determining eligibility?
Verify a patient’s coverage before the appointment using your EHR’s electronic eligibility tool to reduce denials and potential revenue delays.
In addition to that recommended practice, use this checklist to prepare for the visit:
- Look for accounts with inactive plans and alert them.
- Examine your insurance policies for primary, secondary, and tertiary coverage. Remind patients to update their COB with each payer if they have several insurance policies. (It’s worth noting that Medicaid is always the payer of last resort.)
- It’s always a good idea to double-check if a patient’s insurance is “conventional” Medicare coverage if they’re 65 or older.
- Confirm whether the patient’s insurance coverage covers the treatments and whether a referral or prior permission is required.
- Ensure that referrals and authorizations are authorized, placed into the system, and associated with the appropriate appointments.
- Check to see if a benefit limit is stated, indicating how much of the benefit is still available. Some plans may contain restrictions on the amount of money spent on each visit, as well as the frequency and the time range in which services must be provided (e.g., benefit limitations under a patients plan which consists of 12 visits, with a visit limit of two visits each month). Note that certain insurance plans may instruct providers to contact customer service for information on psychiatric and drug addiction benefits.
Determine if you should collect a copayment, coinsurance, or deductible payment.
Keep these measures in mind while arranging the patient…
- Collect as much demographic data as feasible Meaningful Use (MU) reporting will be affected by several demographic characteristics (such as preferred language, sex, race, ethnicity, and date of birth).
- Always inquire whether the patient’s insurance has changed, whether it’s a new policy or a change in coverage.
5.What are the advantages of using a standard operating procedure (SOP) to determine if a patient is eligible?
It is advised that you construct a standard operating procedure (SOP) for the various workflows you use on a regular basis. For example, a recommended discussion track for front office workers to utilize when asking about outstanding balances of patients should be included in the SOP’s guidelines.
Documenting your practice’s operations will give a knowledge library for new staff to grasp the steps necessary to execute jobs effectively and efficiently. Furthermore, the SOP document will foster workplace teamwork by assisting various roles in understanding how their activities affect the RCM.
Frequently Asked Questions
Practices can validate eligibility using computerized real-time checks or manual checks. Electronic real-time eligibility checks are recommended at least 48 hours before the patient’s visit to:
- Verify the patient’s insurance status and benefits.
- Inform patients about copay requirements.
- Ensure insurance details are up to date.
- Request updates on primary care physician (PCP) and benefit coordination (COB).
For manual checks, contact the insurance company using the phone number on the back of the patient’s insurance card or visit the payer’s website.
Eligibility verification requires the following details:
- Subscriber’s name
- Patient’s name
- Patient’s relationship to the subscriber
- Patient’s date of birth
- Patient’s gender
- Patient’s member number
- Group number and name (policy effective date)
Additional information such as other insurance coverage, PCP details, or qualifying status may be required if relevant to the coverage.
Eligibility should be confirmed before the patient’s appointment, ideally 48 hours in advance. However, it can also be verified during check-in. Always update records if a patient’s insurance has changed since their last visit.
The best practices for verifying patient eligibility include:
- Using your EHR’s electronic eligibility tool before appointments.
- Reviewing accounts with inactive plans.
- Confirming primary, secondary, and tertiary coverage.
- Checking for referrals or prior authorizations when required.
- Verifying benefit limits, such as visit caps or monetary thresholds.
- Determining copayment, coinsurance, or deductible amounts to collect.
An SOP ensures consistent and efficient workflows for eligibility verification. Benefits include:
- A knowledge library for training new staff.
- Improved teamwork by clarifying roles in the process.
- Better communication, such as a structured approach for discussing outstanding balances with patients.
Documenting procedures helps streamline operations and fosters an organized approach to revenue cycle management.
