Patients are taking on more financial responsibility as consumption rises. The increasing popularity of high-deductible health plans (HDHPs) is a strong indication of this trend. Determining coverage and fully understanding the patient's responsibility to make upfront payments are vital.
This essay emphasises the significance of verifying patient eligibility and benefits.
What is the difference between patient eligibility and benefits verification?
The patient's insurance coverage for the medical treatments must be confirmed, and the patient's financial obligations must be established. Physician practice are able to check the health plan's coverage, as well as the copayments, deductibles, and coinsurance with the health plan, through the patient eligibility and benefits verification procedure.
The collection of coverage status is encouraged by eligibility verification, and the risk of claims being turned down is decreased. It makes it possible for healthcare providers to obtain payments from clients in a prompt manner and avoids delays in cash realization.
Information needed to verify patient eligibility and benefits
The upfront collection of patient information is a crucial part of front-office duties since it enables insurance verifiers to confirm benefits.
Information Insurance Companies Asks
Subscriber Name
Patient Name
Patient's relationship with the subscriber
Patient date of birth
Patient Gender
Patient member number
Group name and number
Plan type
Patient Address
Information to Check with Insurance Companies
Primary or Secondary
Deductibles
Co-pays
Co-insurances
Payable benefits
Patient policy status
Effective date and Term date
Type of plan and coverage details
Plan exclusions
Claims mailing address with Electronic Payer ID
Referrals & Pre-Authorizations
Life-time maximum, and more
Timely Filing and Appeal limit days
Any other listed active insurance
COB last Updated on
Staffs at healthcare facilities must get training on the procedures for insurance verification. Denial rates are decreased and the cash flow cycle is sped up with efficient processing.
Checklist for Verifying Eligibility
The following are a few excellent practices for determining patient eligibility and benefits.
Check if the plan is active
Always inquire about any upcoming or recent insurance changes with the patient.
Check if the patient has multiple insurances – primary, secondary and tertiary. Ensure patient has updated the Coordination of Benefits (COB) with each payer
Verify the Medicare coverage for patients who are above 65 years of age.
Understand if prior authorization or a referral is required for the specific medical service. If referrals or authorizations are needed, please obtain the same and update in the system.
Confirm if the patient's policy covers the procedure
Some plans may restrict the number of visits and length of time that medical services can be provided, as well as the benefit limits. The front desk needs to gather this information.
Payments must be made by the patient. According to the specifics of the policy, collect the deductible, copayment, and coinsurance payments. The process of pursuing patient collections might be tedious, and you must collect upfront.
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