Eligibility Verification: Most Neglected Process of your revenue cycle management (RCM)

Eligibility verification is an extremely important procedure done by healthcare providers prior to rendering the service to a certain patient. Providers need to get patients’ eligibility details in order to find out if the service they are about to perform is covered by an insurance plan. A properly checked eligibility is key to successful claim payment and an absence of claim denials. Not only does it let providers know if they are going to get paid, but also how much, and if they should collect any patient responsibility, such as copays, deductibles, and coinsurances. As a result, if eligibility is checked correctly, providers face no unreasonable underpayments, and patients are protected from a surprise bill. To discover the strategies of proper eligibility verification, continue reading!

Did you know that two of the top five claim denial reasons are related to a patient’s eligibility? Namely, failure to determine if a patient’s benefit plan covers a specific procedure code, as well as if a provider is enrolled into a patient’s Line of Business are among the leading claim denial reasons that we face on a daily basis. It’s time to investigate & tackle your denials!
But first, what is the eligibility verification? Is this something that you need to do for each patient?
Eligibility verification is a process of confirming a patient’s coverage information with his/her insurance prior to performing a service. There are no specific regulations related to what kind of information needs to be checked upon coverage verification. However, it is strongly recommended to check if a patient’s benefit plan is active on the date of service (i.e. the coverage has not been terminated prior), and if a specific procedure is covered by the plan in an in-network or an out-of-network setting. As a result, eligibility verification allows healthcare providers to predict if they are going to get paid for their services and if they will need to collect any monetary responsibility from a patient. Ineffective eligibility and benefits verification process can result in increased claim denials and underpayments, delays in payments, as well as unnecessary work due to resubmissions or sending bills to your patients.

Top-5 reasons to check eligibility of each patient:
  • Clean claim submission: The accurate eligibility verification process helps to submit clean claims and reduces efforts to re-submit them. Clean claim submissions also ensure quicker payments since you are paid instantly by the correct insurance carrier.
  • Fewer claim denials: If coverage of a certain procedure is verified upfront, there are fewer risks to receive a denial stating that the service is non-reimbursable by a patient’s plan.
  • Reduce write-offs: Upfront determination of patient responsibility for payments reduces patient debts and relieves providers from sending bills for their services.
  • Increased patient satisfaction: Thanks to eligibility verification, patients are well informed about their insurance coverage and out-of-pocket expenses, effectively eliminating a possibility of a surprise bill.
  • A good provider record: Since a proper eligibility verification reduces claim denials, it also protects providers from facing insurance audits, payment recoupments, as well as from participation in training programs, such as the Medicare Targeted Probe & Educate Program.
Top-5 long-run consequences of NOT checking patient’s eligibility on a regular basis:
  • More claim denials: a lot of services are denied since they are not covered, and/or have never been covered by a patient’s plan.
  • More frequent claim resubmissions: unknown changes in patient coverage information may lead to a need for claim resubmission to different carriers.
  • Unnecessary communication with patients: drawbacks in patients’ insurance information that have not been identified prior to rendering a service eventually force providers to contact their patients after the service is already rendered.
  • Significant financial reductions affecting future claims: even though you may receive a payment for a service that is not actually covered by a patient’s plan, insurance may still request their money back in the future, should this error be identified. In some cases, a specific dollar amount may be recouped from your future claims that may not be even related to one particular patient.
  • Participation in Medicare Targeted Probe & Educate program, as well as numerous comparative billing reports: a repeated denial pattern may attract quality assurance & audit analysts of your Medicare Administrative Contractor (MAC).
Now that you have familiarized yourself with the importance of the eligibility verification process, the following question may arise: how do I check eligibility?

There are two ways of verifying patient’s coverage information:
  • The old-fashioned way: by checking the information provided on the back of a member’s ID card, and then calling applicable insurance for details. Before the age of electronic health records and online insurance portals, patients would provide their information either at or before a medical visit. The front desk staff would then contact the insurance provider by phone or fax to verify coverage
  • The modern way: Real-Time online eligibility verification tools (RTE).
While some of you may prefer to get the most up-to-date information directly from an insurance representative, RTE has a strong comparative advantage when it comes to getting eligibility information quickly & efficiently. RTE options allow staff to check eligibility online for Medicare, Medicaid, commercial plans, and sometimes even the Workmen’s Compensation plan members.

There are two main ways for staff to perform real-time eligibility verification:
  • Online Insurance Verification Portals
For medical offices that do not have an electronic health record system (EHR), or choose to do their eligibility checking outside of their EHR, there are many vendors that offer an eligibility verification feature via their online portals. This technology functions as a clearinghouse for multiple insurance carriers. Such vendors normally charge a flat fee for each eligibility transaction. After all the requested information is entered into the system by a provider, the portal will then display a detailed report on a patient’s benefits.  This method has the drawback of not being entered into other electronic systems, so the staff may print or otherwise save copies of the transaction outside of the clinical system of record.
At the same time, all major insurance carriers provide an option to check the eligibility of their members completely free of charge. For example, UnitedHealthcare and affiliated plans make it possible to check coverage information for their members on the Optum (Link) provider portal. In addition, all Medicare Administrative Contractors have their up-and-running provider portals.

  • EHR integration
Eligibility verification tools may be integrated directly into some EHR systems. Should this be the case, a patient’s coverage information may be obtained in a matter of a simple click without even having to close his/her encounter charts. If you use an electronic health record system – contact your IT department to find out if it is possible to integrate an eligibility tool into your software.

Or, you can just trust this to us – we offer a real-time eligibility portal that can also be integrated into an EHR.

WCH Service Bureau Real-Time Eligibility application eliminates the need of calling insurance companies or of getting registered for over a dozen payer-specific portals.

With this application, you can check patients’ eligibility easily for a great deal of payers. Just enter the patient’s demographic and insurance information, and you are good to go!

Our eligibility portal displays the most specific coverage information, such as the effective/termination date, a list of covered services, as well as copays, deductibles, and coinsurances.

Being a leading helpmate of healthcare providers for over 20 years, we have coined our own instruction on proper eligibility verification. Bienvenue!

A patient wants to schedule an appointment at my office and I need to know if the services will be covered by the plan. What do I do?
First and foremost, you need to ask the patient about what kind of insurance does he/she has, if possible. You might already be familiar with the list of payers that you do not participate with, so it is quite possible that you would have to reject this patient straightaway since you already know that you would not get a payment from certain insurance.

Okay, now that you’ve got the name of the insurance, and you are confident that you participate with the plan, it is time to schedule an appointment.

Once the patient is at your office, you would need to collect his insurance ID card, or otherwise, obtain his/her insurance ID. Keep in mind that you would need to obtain the coverage information for both primary and secondary insurance that would cover any patient’s responsibility, if applicable. At the same time, it is crucial to collect demographic information, such as the first/last name, date of birth, and a full address with a ZIP code.  Your intake form may request some additional information based on your individual needs. Here are top-5 things that are crucial for a successfully verified eligibility:

  • Patient’s first/last name
  • Date of birth
  • Insurance name
  • Insurance ID
  • Patient’s address
The next step would be logging in to your EHR or a real-time eligibility portal and entering the information that you have just obtained. Interchangeably, you can log in to an insurance-specific provider portal to check this information.

Once you have entered the above-mentioned information, you will receive a detailed report on what is going on with the patient’s coverage. Well done!

Here is what you need to focus your attention on when looking through an eligibility report, and why you should do that:
  • An effective coverage date, or a termination date, if applicable.  If an effective date is earlier than the date of service, or if there is a termination that has occurred prior to the day when you are planning to accept this patient – an insurance carrier will deny your claim and you would have to resubmit it to a different payer or to bill the patient in certain cases.
  • Places and types of service, as well as specialties that are covered by the plan. If you see that the patient does not have any coverage for outpatient/inpatient procedures performed by your specialty – you will not get any payment for your services.
  • If possible, it is better to check the coverage of a specific procedure code that you are about to perform – some online portals have this option. Verifying the coverage of each service on an individual basis helps you to avoid underpayments.
  • Name of the plan and your participation status, if applicable. Some benefit plans do not cover services performed by non-contracted providers, and it is better to know that beforehand.
  • Out-of-pocket responsibility information. If you fail to verify if the patient has any copays, deductibles, or coinsurance – you are risking experiencing an underpayment for your services since you may simply be unaware of these out-of-pocket expenses.
  • Patient demographics. Sometimes there may be a discrepancy between the patient’s demographic information shown on the eligibility portal, and actual demographics. Ignoring this discrepancy may lead to unnecessary claim rejections, and/or denials.
To sum up, eligibility verification is the most important process of your revenue cycle management because it can directly influence your claim reimbursement flow. Knowing how to handle this process correctly decreases claim denials, rejections, and underpayments.