Improving Reimbursement with a Good Eligibility Verification Process

A poor eligibility verification process is one of the main reasons why reimbursement gets lost or delayed. Since there are a lot of things involved and rules to follow, you must always put eligibility verification as one of your top priorities. This issue does not just involve the income of your practice. Your patients’ satisfaction and overall impression of your practice are also affected by this.


How to establish a good eligibility verification process

To help you get started, we have compiled some of the most critical aspects of establishing a good eligibility verification process as a practice:


  •  Maintain a list of the participating plans

    As a healthcare provider, you should know the exact plans you are participating with, under each payer. It is essential to keep track of these things, as you may be surprised that you’re in-network with UHC Commercial plans, but out-of-network with UHC Medicare advantage plans. You should also take note of the enrolled servicing locations, as you may accidentally render a service that will be processed as out-of-network.


    That is the reason why healthcare providers need to keep tracking current enrollments and make sure that they do not expire. Revalidate and respond to re-credentialing requests to avoid gaps in enrollment and contract termination. Here at WCH, we have an Annual Recredentialing package that includes:


    o   CAQH attestation maintenance

    o   Professional certificates expiration monitoring and updating

    o   Medicare and Medicaid Revalidation

    o   Processing Re-credentialing request from payers

    o   Processing of routine insurance notices and answering provider’s questions about upcoming insurance changes


    If you have questions regarding credentialing services, please contact Olga Khabinskay via email ( or call 888-924-3973 ext. 1201.


  • Check the eligibility and benefits for every encounter of new and established patients

    You should keep a detailed history of coverage for each patient, including their plan’s effective and termination dates. Deleting any information is not recommended, and you must make sure that you have a copy of your patients’ ID cards.


    Additionally, you should make sure that the primary and secondary payers are identified accurately to get a correct list of benefits under each payer. Remind your patients to constantly update their Coordination of Benefits, including workers’ compensation and no-fault cases.


    There will be times when identifying a payer can be confusing. Here are a few rules to help you determine who pays first and second:


    o   Medicaid is always a payer of the last resort

    o   If the patient has two payers (as a spouse and as an individual policy-holder), the primary payer is the one in which the patient is the policy-holder

    o   Birthday rule

    o   Medicare Secondary Payer (MSP) rules


    You should also check the in-and-out-of-network benefits/limitations/exclusions and authorization requirements as well as applicable patients’ responsibility. Collect applicable copayment at the time of services.


  • Always keep proof of eligibility verification, authorization requests, and responses

    This can be anything, from a web printout, call reference number including the date/time the call was made along with a representative name and brief note, faxed copy of the eligibility and benefits verification, among others.


Learn more!

To know more, you should always keep up with news regarding industry and insurance updates. Another way to learn more is through webinars like some of the ones we offer, including the “Eligibility and Authorization” webinar series we hosted at the beginning of 2019.


Let us know if you would like us to resume webinar series on “Eligibility and Authorization the right way.” Click here for a short survey.