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5 Eligibility and Benefits Verification
Challenges that Most Medical Practices
Overlook
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Gain access to the patient’s insurance status and benefits prior to the visit
using this way.
Get updates from the patient and let them know if there is a copay needed at
the time of treatment.
Verify that your insurance is up to current and that your account is marked for
a speedy check-in.
Request that individuals update their primary care physician (PCP) and
benefit coordination (COB).
To validate eligibility, practices can utilize either computerized real-time
eligibility checks or manual checks. Using electronic real-time eligibility to
perform checks at least 48 hours before the patient’s visit is recommended.
Manually assessing eligibility may be necessary to ask the insurance company
specific questions about the patient’s benefit plan, which is less efficient. Simply
dial the phone number on the back of the patient’s insurance card or visit the
payer’s website.
1.How does a practice determine whether
or not a patient is eligible?

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Subscriber’s name
Patient’s name
Patient’s relationship to the subscriber
Patient’s date of birth
Patient’s gender
Patient’s member number
Group number and name (policy effective date)
Every patient should be given the following information:
Additional information may be sent if it is accessible in the health plan’s
database and is relevant to the coverage. Other insurance coverage may be in
force, as well as PCP and qualifying status. This information’s correctness,
however, cannot be guaranteed.
2.What information to provide during an eligibility verification?

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Practices should confirm eligibility ahead of time. The best time is before the
patient sees the doctor, ideally 48 hours before the appointment. Alternatively,
this procedure can be completed at any time before or during check-in. If a
patient’s insurance has changed since their last appointment, front-office
employees should always inquire.
Keep a current, legible copy of the patient’s insurance card(s) on file to refer to
during the billing process, since back-office billers may need to confirm
eligibility when handling rejected or declined claims.
3.When should you verify patient eligibility?

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Look for accounts with inactive plans and alert them.
Examine your insurance policies for primary, secondary, and tertiary
coverage. Remind patients to update their COB with each payer if they
have several insurance policies. (It’s worth noting that Medicaid is always
the payer of last resort.)
It’s always a good idea to double-check if a patient’s insurance is
“conventional” Medicare coverage if they’re 65 or older.
Confirm whether the patient’s insurance coverage covers the treatments
and whether a referral or prior permission is required.
Ensure that referrals and authorizations are authorized, placed into the
system, and associated with the appropriate appointments.
Verify a patient’s coverage before the appointment using your EHR’s
electronic eligibility tool to reduce denials and potential revenue delays.
In addition to that recommended practice, use this checklist to prepare for
the visit:
4.What are the best techniques for determining eligibility?

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Check to see if a benefit limit is stated, indicating how much of the benefit is
still available. Some plans may contain restrictions on the amount of money
spent on each visit, as well as the frequency and the time range in which
services must be provided (e.g., benefit limitations under a patients plan which
consists of 12 visits, with a visit limit of two visits each month). Note that certain
insurance plans may instruct providers to contact customer service for
information on psychiatric and drug addiction benefits.
Collect as much demographic data as feasible Meaningful Use (MU) reporting
will be affected by several demographic characteristics (such as preferred
language, sex, race, ethnicity, and date of birth).
Always inquire whether the patient’s insurance has changed, whether it’s a new
policy or a change in coverage.
Determine if you should collect a copayment, coinsurance, or deductible payment.
Keep these measures in mind while arranging the patient…
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7.
It is advised that you construct a standard operating procedure (SOP) for the
various workflows you use on a regular basis. For example, a recommended
discussion track for front office workers to utilize when asking about
outstanding balances of patients should be included in the SOP’s guidelines.
Documenting your practice’s operations will give a knowledge library for
new staff to grasp the steps necessary to execute jobs effectively and
efficiently. Furthermore, the SOP document will foster workplace teamwork
by assisting various roles in understanding how their activities affect the
RCM.
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5.What are the advantages of using a standard operating
procedure (SOP) to determine if a patient is eligible?

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