Why Patient Eligibility Verification Matters in Healthcare

 

The Significance of Checking Patient Eligibility in Healthcare

Amid the tensions of healthcare billing, patient eligibility verification stands out as a two-pronged weapon against inaccuracies in reimbursements and claim denials. Patient eligibility verification is the process of providing healthcare practitioners with relevant information about the patient’s health insurance and the services about to be performed on the patient. It’s like a bocce ball game; an essential point that allows getting full payment for your services and greatly minimizes the risk of losing income.

Patient-Eligibility-Verification

With the increasing operational expenses and pressure on healthcare providers to be more efficient with their revenue cycles, patient eligibility verification has become an integral step of the process. Given their insurance eligibility, providers can prevent unnecessary claim processing delays, denials and errors, which in turn, leads to quick reimbursement and high levels of satisfaction for the patients.

In this article, we would focus on the importance of checking patient eligibility, what benefits healthcare professionals get from it, and what are the main processes that must be included in policies aimed at its implementation.

What is Patient Eligibility Verification?

Patient eligibility verification is the work of confirming insurance details or financial eligibility by healthcare providers when patients are requesting or seeking any medical services. Such services provide assurance that the insurance policy tendered by the patient will accommodate the medical services prescribed to him or her and any other costs that may be incurred such as copayment, coinsurance or insurance deductible.

Eligibility verification procedure entails the verification of certain essential particulars on the patient’s insurance card with the respective insurance provider. This may be achieved either through contacts made to the respective insurance providers or electronically via EHR, billing systems or other integrated systems.

Irrespective of the method used, patient eligibility verification is critical in making sure that the following are met:

• The patient’s insurance policy is valid and not expired

• The provider will be reimbursed for the offered services

• Patients are given non-emergency services with full knowledge of out of the pocket costs

When eligibility verification is performed prior to the delivery of health services, there are far less claim denials, delays, administrative pain, and other inefficiencies that face the healthcare organizations revenue cycle.

Why is Patient Eligibility Verification Necessary?

1. Reducing the Number of Claim Rejections and The Time Taken To Process Claims

The first reason that justifies the need for patient eligibility verification is that it helps in minimizing the rejection and delays of claims. Insurance providers can refuse to pay claims when the insured is not covered at the time of service, the patient goes to an out of network provider, or the treatment funded by the patient’s scheme is not included in the patient’s policy. If a patient eligibility verification is done before service is provided to the patient, the provider can overcome any complications regarding the patient’s insurance coverage for the procedure.

Without the verification requirements, healthcare providers may be forced to pursue claims on the basis of information that may be incompatible with current insurance records. The appeals process can be lengthy, including resubmission of claims, and numerous phone calls to insurance payers. Not only does this increase the lapse in time before payment is received, it also raises the overhead expenses in administrative matters.

2. Better Management of Cash Flows and The Revenue Cycle Of The Practice

The effectiveness of practice management in conducting patient eligibility verification has a positive correlation with the revenue cycle management of a practice. Because patients will probably be able to submit clean claims on time, healthcare practitioners will probably be able to provide up-to-date and correct insurance information. This enhances the cash flow and contributes to the practice’s financial soundness.

Adequate verification of benefits assists in maximizing up-front patient payments since it allows providers to collect appropriate copayments, deductibles, or coinsurance at the outset. This will also ensure that there is a reduction in claim denials and reworking which is advantageous to practice financial performance. 

3. Improving Patient Experience 

10Then it comes to any medical practice including medicine, patient satisfaction remains paramount for success. And here is the approach that could help gain the most - address any financial concerns even before a patient is seen. If a patient is informed about their benefits, costs that they are required to pay out of their pocket, and any problems that they may encounter with medical necessity beforehand, there are fewer chances of confusion occurring later.

Furthermore, addressing the problem of verification issues tend to minimize the problem of billing disputes because patients already know upfront what their insurance policy entails. This increased transparency helps to foster patient trust and satisfaction thus adding more positive reviews and referrals segments for your practice.

4. Making the Billing Process More Efficient 

Integrating patient eligibility verification into the pre-service phase would largely simplify the billing process for healthcare practices. Even when such billing codes are utilized, billing trained professionals make sure that all needed information is up to date so that claims can be properly submitted right from the outset. This minimizes the chances of rework and back-and-forth exchanges with insurance companies which enables the billing department to function more productively.

Furthermore, with the appropriate technology, the process of eligibility verification of patients can be done automatically which minimizes time wastage and human errors. Integrated billing or EHR software allows automated eligibility checks so that healthcare providers are ready with the necessary insurance coverage of patients without any interruptions in the service delivery.

5. Adherence To The Insurance Regulations

As part of the contractual obligations between the healthcare provider and the insurance company, patient eligibility verification is required by healthcare practices on a number of insurance providers. If the eligibility verification checks are not done and the patients are issued with services anyway, this may amount to breach of rules regarding healthcare services and these are the basis of the contract with the insurance allocate. 

Through the eligibility verification, healthcare facilities confirm no breach of the rules provided by health insurance companies and government agencies that govern the operations, thus minimizing the chances of penalties or audit. In addition, correct eligibility verification helps healthcare facilities demonstrate that they are compliant with industry standards, hence their compliance position is enhanced.

Steps Involved In Patient Eligibility Verification

As defined by the name, there are processes involved in the verification of patient eligibility. Below are the process steps that are commonly utilized by healthcare practitioners. 

1. Collecting the insurance coverage for the patient

The first step in eligibility verification is verification of patient information about their insurance such as their insurer. This usually includes the name of the insurance company, policy number, group number and other relevant information from the patient’s insurance card.

2. Interacting with the Insurance Company 

The subsequent task is to check the insurance information if it has been collected which can be done through contact with the insurance company through a number of ways: 

Direct confirmation: contacting the insurance provider to check coverage and eligibility details simply by means of phone call. 

Indirect confirmation: Information can also be obtained indirectly through electronic health records (EHR) or through billing systems that are onboard with the insurance company. 

3. Determining Coverage and Benefits 

Having reached the insurance company, the provider will check if the patient’s insurance covers the desired services. This includes searching for any restrictions or exclusions such as if the provider is out of network or a certain procedure is not listed under the patient’s plan. 

They also consult regarding the patient out of pocket copayments, deductible and coinsurance amounts. 

4. Updating the Eligibility Information 

Upon expiration of the verification of eligibility, the provider is expected to include the patients’ eligibility status into the medical records/billing systems. This helps verify that eligibility was met which gives convenience in regard to making submission of claims later.

5. Informing the Patient 

The process ends with a notification of the patient of their most recent eligibility status as well as their own cost payment and out of pocket expenses, which are likely to be incurred. With this type of understanding, the patient is able to prepare for the cost implications of such services and the likelihood of any surprises emerging after the service has been offered is low.

Role of Mava Care Medical Billing Company in Patient Eligibility Verification

For the best and most appropriate patient eligibility verification procedure, many healthcare providers seek services of specialist billing companies such as Mava Care Medical Billing Company. Mava Care Medical Billing Company focuses on eligibility verification, revenue cycle enhancement and improving the rate of acceptance of claims.

With the assistance of Mava Care Medical Billing Company, medical practices are assured that the crucial step of eligibility verification will be done efficiently and on time. The company's qualified staff effectively utilizes the newest technologies and market knowledge to conduct instant eligibility checks which help providers to be compliant and get paid on time. 

Benefits of Outsourcing Patient Eligibility Verification

There are various benefits associated with outsourcing patient eligibility verification to reputable companies such as Mava Care Medical Billing Company:

Expertise: 

It is evident that Mava Care Medical Billing Company has worked in this area and can handle such processes, thus encouraging accurate and compliant outcomes of insurance verification.

Time Savings: 

Healthcare organizations do not need to worry about the administrative aspects of the practice since those are taken care of by the Mava Care Medical Billing Company. They can concentrate on patient care.

Reduced Denials: 

Mava Care Medical Billing Company can also capture claim denials by ensuring the accurate verification of eligibility. This helps improve cash flow and minimizes rework from denied claims.

Cost Efficiency:

Practice owners and managers can rely on the verification provided by third party firms rather than paying a team to perform the verification process in-house which saves operational expenses.

Conclusion

The management of a patient’s financial liabilities and the collection of payments for services offered by various US doctors is referred to as the “healthcare revenue cycle". Eligibility verification is one of the core functions that help reduce the chances of denied claims as well as enhance the billing processes of providers, thereby boosting the client's' convenience.

Mava Care Medical Billing Company offers an attractive option for healthcare practices seeking to streamline their eligibility verification processes. To enhance their financial health and operational efficiency, practices can focus on precise and prompt eligibility verification by utilizing their capabilities.