Insurance Eligibility Verification - Getting It Right the First Time

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Insurance Eligibility Verification - Getting It Right the First Time

By Ann Bina, Chief Compliance Officer, Compliance Specialists, Inc.

Higher deductibles, increased co-insurance, tighter participating networks, outsourced vision benefits, Medicare Advantage Plans, Medicaid HMO Plans and health insurance exchange offerings are just a few of the things that can cause issues for your office. Is it any wonder that patients become confused when asked about their insurance?

The days of insurance paying for the service in full are gone and practices need to implement processes to ensure payment is received for services performed. Unfortunately, the less you know about a patient’s coverage before you see them, the less potential you have to get paid in a timely manner.

Creating a patient eligibility process can enhance up-front collections and ensure payment from the appropriate insurance company. To be successful, this process should start with the first contact made when scheduling the appointment, whether the patient schedules over the phone or through an on-line program.

Initial information collected should include:

  • Patient name (including middle initial)
  • Patient date of birth
  • Patient address & phone contact information
  • Insured name
  • Insured date of birth
  • Insured address
  • Insurance ID
  • Group Number
  • Insurance contact number from the back of the card

Prior to the scheduled appointment your office should contact the insurance company using the number you obtained above and verify that the patient is covered by this plan. At this time you should be able to determine if services performed in your office will be covered and if the patient will have any out-of-pocket responsibility. It is beneficial to verify the claim filing address as well as the electronic payer company number during this call.

Checking eligibility can be a time consuming process and it is understandable that many practices do not have staff that can be easily allocated to this work. Many clearinghouses have eligibility functionality that may assist in the process. There are also third party vendors available that may be a cost effective solution. When considering if you should partner with an outside vendor, review the eligibility response that is returned from the payer to ensure it contains everything you need. If not, look to other vendors until you find what you want.

When you confirm the appointment with the patient inform them of what they will be expected to pay at the time of service. While these calls may be uncomfortable, it is great customer service to your patient and ensures no surprises at the time of service. If your eligibility check indicated that the service would not be paid for or that your office is out of network, the patient will be able to make an informed decision on their care. It may be that they cannot pay for the service in full and may need to seek care where their insurance benefits can be better utilized.

When the patient arrives for their appointment, your office should review all of the information obtained to date and collect any discussed payment amount. You should also take a copy of the front and back of the insurance card and make sure it is available for staff or vendors responsible for billing.

The final step is to monitor your success. Since eligibility issues result in rework, delayed payment, increased denials and decreased customer satisfaction, you can measure this in a number of ways:

  • Monitor the number of claims rejected in the clearinghouse as ID number not found
  • Monitor denials such CO-22 (covered by another payer), CO-27 (coverage termed), CO-28 (coverage not in effect), CO-33 (no dependent coverage)
  • Monitor the total copay amounts collected at time of service
  • Monitor customer feedback

If the numbers of rejections and/or denials are decreasing, you know your process is working. If copayment collections increase and customer feedback is positive, your process is also successful.

The challenge of obtaining insurance payment in a timely manner will continue. Now is the time to create processes that will assist you in collecting the correct information and shortening the time it takes to get paid. In the short term, implementing a successful eligibility verification program may seem overwhelming. However, in the long run, the investment of staff time or outside resources to get it right the first time will be worth it!