11 Must Have Attributes for Efficient Insurance Verification Solutions

Comprehending medical insurance coverage is beyond the realm of many patients.

The responsibilities of accomplishing a patient’s insurance verification, therefore, lie with medical practices. It is important that this is done in advance before the patient comes for treatment so that the services rendered by the practice are reimbursed.

The most practical approach of doing it is using a Patient eligibility verification tool. Quite a few billing companies offer this functionality, through their platforms. Most important however is to know the features this tool provides. So always be on the lookout for a tool with these eleven features:

1. Does this tool interface with practice management systems?

With the billing company providing the service and the tool, the in-house staff of the practice can be relieved of the responsibility, and instead focus their priorities on patient care. It also alleviates the need of the practice to train the in-house staff in operating the tool.

2. Does the tool have the capability of scrubbing patient and insurance information for entireness and errors?

This essential feature scrubs patient and insurance information for entireness and errors, with returning results enabling the service provider to rectify and amend the information, before the scheduled visit of the patient.

The most important aspect of this feature is that once the missing information of the patient has been discovered, the front office will be alerted to call the patient or the carrier to gather the missing information, which could include the patient’s member ID, insurance company name, DOB, etc. Adding the information into the system should be easy and minimal time consuming.

3. Does the tool enable eligibility requests to be resubmitted with corrected information facilitating the patient verification before the scheduled appointment?

At times, it becomes necessary to verify insurance verification a number of times, prior to an appointment. Each time the verification is done, the system should have the ability to store the insurance verification result in its database.

4. Does the tool allow key-entry eligibility requests to be submitted to insurance companies offering EDI, to gather critical insurance information prior to emergency situations or facilitating last minute appointments?

In the routine practice, the insurance verification is automatically accomplished two days before a visit. The verification should also be done on-demand, at any point-in-time by the front-office employees.

5. Does the tool provide complete benefit data about every patient, notwithstanding their insurance and EDI availability?

After aggregating only the patient’s name & DOB, the tool should integrate with your scheduling software and be capable of delivering precise up-to-date data about patient’s insurance in real time.
The information about each patient’s insurance must include the following:

Name of carrier with the complete list of all active and inactive plans

Year of commencement/ Policy Year

Individual Plan Deductible and Deductible Remaining

Family Plan Deductible and Deductible Remaining

Per Code Coverage

Procedure Frequency Limitations

If Waiting Period is Satisfied or Not

Active Date

Maximum Individual Plan and Maximum Remaining

Family Plan Maximum and Maximum Remaining

Coverage Per Category

If Deductible Applies to a Certain Procedure or Not

Procedure Age Limitations

Recent History of Certain Procedures

The tool should have the ability to automatically generate a dialer task to call the insurance company, in case of any important missing information. A call script must be generated by the tool to include questions that need clarifications. The gathered information shall automatically be saved in the system for future reference.

6. Does the tool support insurance verification in real time?

Displaying patient’s insurance verification details in real time is a big plus, it does away the need to follow-up with the carrier seeking clarification of any details.

7. Does the tool support multiple patients verification at the same time?

The tool should be most suitable for large organizations, accountable care organizations, hospitals & large practices. It should be highly scalable and best suited for eligibility checks in batches. Regardless of the number of patients, the tool should function at an optimum capacity and deliver quality reports on the eligibility status of each patient in the batch.

8. Does the tool have a capability to calculate & estimate patient responsibility and insurance payment?

The tool must have the capability to calculate the deductible, benefits coverage, co-pay, or co-insurance options. If any key information associated with the computed estimates of patient’s responsibility and insurance payment for each appointment is found missing, the system should generate a dialer task for the front office, seeking information from the insurance company for the missing details. Following the gathered information, the system should automatically save the information, with estimates appropriately calculated.

9. Does the tool have a pre-authorization functionality?

In order to bill for the rendered services, an authorization is required by some insurance companies. The tool must have a feature to enable tracking authorizations, and simultaneously send an alert to the front-office staff members, when authorizations have been completely consumed

10. Does the tool have the capability of saving all historical insurance verification results within the system?

The whole continuum of treatment should be tracked by the tool to identify any changes in the patient’s eligibility criteria. The patient information page will display insurance verification results for all their appointments, and subsequently on the appointment page, verifications related to the current appointments will be reflected.

11. Does the interface display all insurance verification results?

A single interface must facilitate the display of all insurance verification results for a certain date period. An overview enables a quick assessment of the current state of affairs, leveraging a practice to plan strategies for the effective functionality of running the practice.

In a final analysis, electronic eligibility systems streamline the entire process, cutting down delays and denials. An automated insurance eligibility verification solution helps a practice divert the in-house staff to high-priority areas, doing away with time-consuming routines, facilitating insurance verification prior to all appointments, pre-authorizations before every test or procedure, and tracking available and expired benefits.