What Is Eligibility Verification and Its Steps?

Failure to validate patient insurance coverage can substantially impair healthcare providers’ financial operations. Inaccurate patient data, expired insurance policies, and failure to comply with pre-authorization procedures are common causes of claim denials and payment delays. Given that individuals are increasingly responsible for more of their healthcare costs and frequently change insurance providers, the work of determining eligibility has become more difficult. Furthermore, as the number of patients grows, so does the risk of mistakes in manual verification processes. Using software for health insurance eligibility verification provides a solution to these issues. 

Nothing aggravates healthcare managers more than needless denials that result in considerable financial losses. According to a poll, over one-third of healthcare leaders indicate that 10–15 percent of claims are rejected, resulting in billions of dollars in lost income. Implementing an automated system via insurance verification software reduces errors and denials and offers significant financial benefits across the revenue cycle. 

Understanding Eligibility Verification

Eligibility verification is comprised of confirming that a patient’s insurance information is correct and that the healthcare treatments they seek are covered under their current coverage. Healthcare providers must confirm a patient’s insurance status before providing treatment. This confirmation procedure entails authenticating active insurance enrollment and guaranteeing that the patient’s coverage covers the cost of specified healthcare services and products. 

The whole process of insurance verification encompasses several key activities, which are as follows:

  • Verify the patient’s name and contact information, and ensure that the information on their insurance card corresponds to what is recorded in their digital health record. 
  • Determine if the patient’s insurance plan covers the planned services without any exclusions. 
  • Ensure that the patient satisfies the criteria for the anticipated services or treatments, such as completing all pre-authorization or referral requirements. 
  • Reconfirming that the patient’s insurance is active and that they have not exceeded any predefined yearly or lifetime coverage limits. 

Healthcare professionals risk not getting reimbursed if they do not have a thorough understanding of a patient’s qualified benefits and other policy details. As a result, it is critical to undertake these verifications prior to a patient’s visit or treatment to avoid billing issues and payment delays. This strategy gives providers confidence in collecting reimbursements for their services while also making the patient registration procedure easier. 

Manual verification is frequently an onerous and time-consuming operation. Employees are charged with exploring specific payer websites or calling insurance providers to obtain the necessary information while engaging with patients. Using medical claims clearinghouses for batch processing provides a more simplified technique for undertaking eligibility verifications. 

The advantages of automated systems include improved capability for detailed reporting and analytics. A platform that collects performance indicators may provide executives with real-time status updates and allow employees to identify areas for improvement. 

Furthermore, providers must choose a software solution that easily interacts with their existing digital infrastructure in order to harness the benefits of data analytics and increase operational efficiency. Connecting to EHR, for example, helps speed up the verification and registration procedures by combining patient information into a single database.

Leave a Comment