Why is it important to verify health insurance eligibility prior to the treatment?

Any health care provider is tasked with achieving two inter-related goals; optimal patient care and efficient revenue cycle management. In a virtuous cycle, physicians utilize decades of learning and experience in service of their patients’ care while administrators/executives employ tools like ‘Health Insurance Eligibility Verification’ to ensure the financial well being of the organization on which the entire enterprise depends.

verify health insurance eligibility

To understand its importance, let us observe a typical verification process in action with a health provider working in tandem with a professional medical billing and coding services company.

A patient calls the front desk of the neighborhood clinic and complains of an excruciating headache.

The front desk executive turns to her workstation running a state-of-the-art medical software which combines the functions of the calendar, electronic health records, practice management, and billing into an all-in-one intelligent solution. Working within the software interface, she schedules an appointment with a physician, confirms there is no existing record of the patient, enters contact details, inquires about health insurance policy particulars, enters the same with patients consent, and initiates a verification check.

The software uses the secure EDI (Electronic Data Interchange) standard to transfer patient details to the office of the medical billing and coding company with the verification request. A trained coding and billing professional takes charge of the process. His first task is to gather all relevant information including but not limited to: policy status, payable benefits, co-pays, co-insurance, deductibles, exclusions, lifetime maximums, special features, claims mailing addresses, and effective dates. He navigates to the insurance provider’s portal on the internet and starts gathering information. Needing further clarification about certain points he calls up the insurance company and the patient. He also takes a look at the latest amendments to the state-level rules regulating the insurance business.

Using the above information, a summary is created in a standard format, mapping the patients’ coverage by charting its various features and boundaries while flagging any major deviations like out of coverage, missed payments, and incorrect personal details.

The patient, clinic front desk, insurance provider, and medical billing and coding company work together to rapidly resolve major deviations if any.

The patient is glad that the discrepancy has been sorted out from the comfort of his home; visits the clinic at the appointed hour and meets his physician who conducts a clinical examination.

A successful verification check gives his physician the confidence and knowledge to recommend a course of treatment that will ensure his well-being while also guaranteeing that there will be little chance of claim denial in the future.

In consultation with his physician, the patient leverages the special features of his insurance plan to ensure that his out-of-pocket expenses are kept to the very minimum.

Verifying the health insurance eligibility prior to treatment helps you offer a seamless experience to the patients, and minimizes claim denials. When executed by trained professionals from medical billing services companies, the Health Insurance Eligibility Verification process ensures zero surprises and nil revenue leakages later on.

Atlantic RCM is one of the leading multi-specialty medical billing companies in USA that serves 25+ major medical billing specialties. Our experts work across your practice in billing, collections and account receivables management, to help you succeed.

Get in touch with the leading medical billing outsourcing company to learn more. Call us at (469) 501-1500 or write to us Info@atlanticrcm.com