Eligibility & Verification Process in Healthcare
The accurate and prompt receiving of information on insurance coverage is essential for revenue cycle management, and insurance eligibility verification is a key component of that. Most claim rejections occur because a patient is not qualified for the services that the provider has invoiced.
Healthcare providers can submit accurate claims with the use of eligibility verification procedures. It prevents claim resubmission.
But a lot of healthcare practitioners don’t pay close attention to the procedure of determining insurance eligibility. Healthcare professionals and people alike are perplexed and ignorant of how the insurance system operates. The technique for determining insurance eligibility was thoroughly outlined in this article, along with its advantages.
What Is Insurance Eligibility Verification In Healthcare?
A patient’s insurance must be verified in terms of three separate statuses, including coverage status, active or inactive status, and eligibility status. This process is known as insurance eligibility verification. Verifying insurance eligibility is crucial since it has a direct impact on whether a healthcare practice will be paid for claims or not, particularly when it comes to account receivables (A/R).
Verification of Insurance Eligibility Process
The following steps are included in the eligibility verification process:
Scheduling of patients:
The online scheduling tools aid in further streamlining the scheduling procedure with the aid of automated appointment scheduling software. It is simple to automate mundane administrative operations like booking replacement appointments for cancelled ones and sending appointment reminders through text, phone, and mail.
Patient Enrolment:
The essential data for the healthcare sector is patient information. The most important issue, however, is what information about the patient’s health should be included and what should be excluded. For instance, a patient’s name, date of birth, and residence are vitally crucial, as are their diagnosis, allergies, and medical history. Contact details such the patient’s emergency contact, primary care physician, and insurance company may be recorded elsewhere under particular headings.
The confirmation of eligibility
The most crucial stage of the RCM procedure is the verification of eligibility. When done correctly, it immediately results in a rise in the number of valid claims. Major problems including delayed payments, billing errors, and non-payment are resolved through a seamless insurance eligibility verification process.
The coverage and benefits provided by the patient’s insurance plan should be reviewed on a regular basis. Because any changes, such as those related to marital status, birth, and divorce, may affect coverage and benefits, it is necessary to keep an accurate record of patient information for this. It is a smart idea to inform the patient about advantages like co-pay, and deductibles, and all through organization administrations.
Prior approval
In revenue cycle management (RCM), prior authorization is crucial because payers need to know whether a specific drug or treatment will be accepted. Healthcare providers should wait until they have insurance company clearance for certain treatments or medical equipment, or else they must contact the insurance companies to inquire about the approval procedure before taking the appropriate action.
Patient Collaboration:
Prior to collection and proper maintenance, all patient data, including contact information, basic information, and health records, should be gathered. Contacting the patients for accurate information is advised if any extra information is needed, such as medication specifics.
Update to the billing system:
The patient information, including insurance coverage data, is updated in the medical billing software. To prevent claim denials, use the sophisticated verification system to collect the insurance card and confirm the patient’s eligibility at each visit. By choosing eligibility and benefits verification services you can determine the patient responsibility for the upcoming visit.
Insurance Eligibility Verification Benefits
Submit a clean claim
With correct eligibility verification, healthcare providers may submit clear claims without having to resubmit them, which decreases rejections and denials based on demographics or eligibility, boosts upfront collections, and improves patient satisfaction.
Increased Cash Flow
A more recent eligibility check results in fewer claim denials and improved claim submission. By reducing write-offs and providing better patient care, it aids healthcare organizations in maintaining cash flow.
A productive workflow
The entire revenue cycle management process is improved by healthcare credentialing services. Less claim denials and better patient experiences will result from a streamlined and effective system.
Self-Pay Revenue Growth
As patient information is electronically connected with the healthcare database, self-pay revenue will rise. This streamlines the payment process for self-pay customers by assisting patients whose “cover” is unknown by assisting them in submitting their claims after cross-checking their eligibility and cover status online.
