5 Easy Steps of Patient Eligibility Verification

Patient Eligibility Verification

The procedure through which healthcare practitioners confirm a patient’s insurance status is known as insurance patient eligibility verification. To avoid:

  • Account receivable billing (AR)
  • Claim denials
  • Payment delays

Healthcare providers must confirm a patient’s real time insurance eligibility verification. Each of these is essential to the revenue cycle of a healthcare provider and affects the provider’s ability to make money.

Many claim statuses may be used to describe a patient’s insurance, including submitted, received, pending, accepted, and denied. Patient claims are frequently denied for the following reasons:

  • Missing patient data
  • Billing claim mistakes
  • Out-of-date rules
  • Duplicate data

Get Insurance in Real Time Authorization

Before delivering non-emergency medical treatments to a resident, a long-term care facility should inquire about pre-authorization-authorization services from the insurance payor. Also, before performing treatments or providing services during the pre-admission phase, a long-term care facility’s billing staff should get authorization from the insurance payor.

Verify the Claim’s Authenticity to see if a patient has active insurance coverage. Before providing care, a facility must confirm the patient’s eligibility verification; otherwise, they can avoid getting reimbursed for their services.

These real-time eligibility or simple tie insurance eligibility verification procedures may seem tiresome and time-consuming. Still, they are crucial for the facility since they guarantee the right payment for the services provided to patients and residents.

How to Ensure Patient Eligibility verification?

Long-term care facilities should have real-time eligibility verification of patient insurance. The procedure of health insurance and how it affects patient care and the payment process are better understood by independent medical billing services.

Since patients might need to comprehend their insurance coverage, long-term care institutions must provide enough training in the insurance eligibility verification procedure. The facility’s employees must clarify the procedures when queried about insurance-related matters. Hence, there will be fewer payment concerns and disagreements if a facility fosters a healthy payment culture. These procedures can be made easier.

Five Ways to Verify Your Eligibility

Most long-term medical billing companies will initially look into the legitimacy of insurance claims using eligibility checks. As already said, insurance eligibility verification establishes whether a patient qualifies for benefits under their insurance payment schedule. Before providing care in such circumstances, a long-term care facility must confirm the resident’s eligibility.

Facilities can estimate the overall resident expenses and the precise amount the insurance payor will cover and repay by using the Verification of Benefits, which shows what the insurance payors cover for certain services. However, it is important to remember that every insurance payor offers various services. So, before services are provided, the resident’s member plan must confirm what services are covered.

Also, institutions must comprehend eligibility claims and collect accurate patient insurance data. It should be noted that patients who are covered by their employer’s insurance plan may experience issues. This is because it is common for patients to be made aware of all the specifics of the treatments their insurance policy covers, necessitating the need to confirm insurance eligibility.

The billing staff of a facility follows a set procedure while conducting eligibility checks to ensure they get accurate insurance information. According to revenues, the following five stages determine a patient’s insurance eligibility.

Step 1: Get the Patient’s Insurance Information.

During the insurance eligibility verification process, the billing staff must ask pertinent questions to get the necessary data, such as:

The hospital’s instruction handbook for insurance verification is displayed to a patient by a doctor. And the hospital’s insurance verification training manual must be followed by all facilities.

  • Name, birthdate, residence, and social security number of the patient
  • the patient’s insurance member ID number, the insurance payor, and their contact information
  • Any necessary authorizations
  • Necessary references
  • All applicable deductibles
  • Address for submitting claims

It may take time to gather the necessary insurance information, particularly if the patient has many insurance plans. The billing staff must obtain the necessary data for each insurance policy. 

Step 2. Create a Copy of the Patient’s Eligibility Verification Card

The information about the patient’s insurance is now available to the institution electronically, which may be recorded in the long-term care EHR. The duplicate can be used as a backup to repair any typing errors in the insurance information that may have occurred. Before submitting a claim, staff can utilize this information to verify the patient’s insurance ID numbers.

Step 3. Call the Insurance Payor or Insurance Provider

Even though a patient may have originally shown an insurance card, insurance coverages are subject to modification or termination. Hence, to confirm the patient’s current eligibility status, facilities must contact the insurance payor. Obtaining up-to-date insurance data and upgrading the long-term care software with it

Step 4: Verify the Accuracy of the Resident’s Information

Billing personnel must receive thorough training from facilities on accurately capturing and transcribing resident data. To submit an accurate insurance claim, such information must be gathered, and even one mistake might result in payment delays or denial of the claim. A facility’s revenue cycle will suffer due to these delays. 

Because of this, the institution must give workers specific instructions in the training manual for insurance verification. Certain long-term care software systems will also include capabilities to simplify their insurance verification policies and practice, saving your team time and assisting them in remaining in compliance with laws.

Step 5: If Required, Follow up with the Residents

If a facility worries about a resident’s insurance details, it should learn more about the patient’s eligibility. Facilities can utilize the resident’s “member services” or “provider portal” to get additional information, conduct an internet search for resources that allow insurance payers to check applicants’ eligibility or both. In such circumstances, it is advisable to notify the patient as soon as possible. Consumers must know they may have to pay out of pocket if the insurance information is not retrieved.

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