Streamlining insurance eligibility verification in your medical practice: Three FAQs
It’s a dreadful scene that occurs every January—the long line of patients, many of whom recently switched health insurance plans, waiting to check in for their appointments. Maybe patients chose a new health plan because they wanted a lower deductible or a lower monthly premium. Maybe they wanted access to a larger network of healthcare providers or better prescription drug coverage. Maybe they finally decided to sign up for a Medicare Advantage plan instead of Original Medicare. Or maybe their employer switched plans, and they didn’t even realize their insurance changed.
Whatever the scenario, the impact of health insurance changes during open enrollment is the same: More work for revenue cycle management staff tasked with collecting and validating new information. This extra work does not usually prompt hiring more staff. Most practices cannot afford to do this. Instead, they ‘make do’ with the staff they have, but they embrace best practices—specifically, they learn to leverage technology (i.e., an insurance eligibility checker) along with new workflows to enhance the efficiency of the entire insurance eligibility verification process.
Here are three FAQs about insurance eligibility verification along with our best advice on how to improve revenue cycle management processes at your medical practice:
Q: Every January, we notice a sharp uptick in denials due to expired health insurance coverage. What is the best way to avoid these problems and focus on eligibility and benefits verification?
A: The most crucial step you can take is to collect health insurance information at the time of scheduling. Require patients to provide this information regardless of whether they schedule an appointment online, in person, or via the phone. If patients cannot provide their updated health insurance information at the time of scheduling, let them know they will need to re-contact your medical practice when they have the information handy.
With that said, be prepared to educate patients about why you require this. Tell patients, ‘We check your insurance eligibility because it helps us reduce the likelihood you will receive a denial or incur costs you don’t anticipate. It gives us time to figure out exactly what your health plan will cover.’ The goal is to make patients feel as though you are watching out for their best financial interests (while simultaneously protecting those of the medical practice).
Once you have the patient’s health insurance information, you can perform real-time eligibility and benefits verification. What is insurance eligibility verification? Verifying eligibility is about making sure the patient’s health insurance plan is active. Verifying insurance benefits, on the other hand, is about confirming whether the patient’s policy covers a specific service or procedure. Just because a patient’s plan is active doesn’t mean they have coverage for the treatment or service they seek.
If you see any red flags pop up during the insurance eligibility verification process (e.g., you discover the patient needs a healthcare referral to see a provider at your medical practice, healthcare services aren’t covered, or you’re an out-of-network healthcare provider), now is the time to contact the patient directly and let them know. Do this before they present for their appointment.
Q: At our medical practice, front-end bottlenecks during open enrollment frequently cause back-end delays for our clinical staff. How can we address this while promoting proper insurance eligibility verification?
A: The easiest way to reduce check-in bottlenecks is to ask for insurance information at the time of scheduling and then leverage mobile patient check-in when patients present for their appointment. Ask patients to scan a QR code using their mobile phone to complete the intake process and validate health insurance information. Mobile patient check-in allows certain patients to flow seamlessly through the check-in process while enabling front-desk staff to give other patients more one-on-one attention (e.g., to discuss healthcare payment plans or loan options).
Q: We have a process in place for insurance eligibility verification, but I am not sure whether we are getting all the information we need. What questions should we be asking when we use an insurance eligibility checker?
A: As you validate eligibility and benefits, be sure to collect the following information:
Annual or lifetime limits
Coverage for specific healthcare treatments and services, including requirements for behavioral and mental health, substance abuse, and addiction
Effective date of the healthcare coverage
Exclusions of coverage that may apply
In-network vs. out-of-network status
Necessary pre-authorizations
Thresholds for deductibles, copayments, and co-insurance
Be sure to recheck insurance eligibility at each appointment. You cannot ever assume a patient’s coverage is active just because it was active the last time they came into your medical practice.
Conclusion
Insurance eligibility verification is an important part of overall revenue cycle management. With the right tools and workflows in place, medical practices can streamline the entire process to promote revenue integrity. Learn how edgeMED can help and be sure to check the Healthy Snacks blog for more expert insights, best practices and industry trends.
