insurance eligibility verification graphic

A Complete Guide to Medical Insurance Eligibility Verification

Medical insurance verification is the process in which a medical billing team determines a patient’s insurance coverage for medical services, as well as the patient’s financial responsibility. Your medical billing staff should complete insurance verifications before scheduling services. This early verification benefits both your business and the patient.

How Does Insurance Eligibility Verification Benefit Providers?

  1. It allows you to estimate what a patient will owe for the services, which helps you to collect payment at the time of service. 
  2. It allows you to gather any necessary authorizations before providing care or services.
  3. It promotes higher clean claim rates by making sure you bill the correct insurance. It also helps determine the billing order (in cases where a patient has more than one active policy).

How Does Insurance Eligibility Verification Benefit the Patient?

  1. It helps patients plan for their financial responsibility, minimizing stress or worry over a surprise bill.
  2. It gives patients a chance to look for another, lower-cost provider or a different insurance policy.
  3. It allows patients to plan for services.

Why is Medical Insurance Eligibility Verification Important?

Medical insurance verification is the first and most important step of revenue cycle management. It helps your organization’s financial security and minimizes claim rejections. If you provide services without verified insurance, a claim may be a loss from the beginning.

Identifying service costs before a patient receives care can also drastically improve the patient experience. 

If you don’t have an efficient insurance eligibility verification process, there can be several negative side effects, including:

  1. You provide care to patients with inactive insurance policies.
  2. You don’t secure authorizations before providing services, which results in claim denials. 
  3. You can’t accurately explain the patient’s financial responsibility, which often leads to delinquent accounts that are ultimately sent to collections.
  4. Patients may get frustrated by your inability to explain coverage and ultimately seek care elsewhere.

What Are the Advantages of the Insurance Verification Process?

Figuring out the patient’s responsibility prior to care is critical. Not only does it enhance the patient experience, it also improves your revenue cycle. When you know the patient’s responsibility, you can collect more co-pays or coinsurances upfront. By increasing upfront collections, you can improve your cash flow and minimize revenue collection delays.

How to Verify Medical Insurance Eligibility

Medical Insurance Verification Process

  1. Obtain patient demographics (name, date of birth, address, insurance provider, etc.).
  2. Copy both the front and back of the patient’s insurance card.
  3. Add the patient to the EHR, PM or RTE tool. 
  4. Add the patient’s insurance information into the EHR, PM or RTE tool.
  5. Check the patient’s eligibility electronically by selecting the appropriate benefit and service type.
  6. Identify the following information from the eligibility check:
    • Who is the policy holder?
    • What is the policy effective date?
    • Does the policy have a term date?
    • Does the patient have a co-pay or coinsurance?
    • What are the patient’s deductible and accumulations?
    • What are the patient’s out-of-pocket maximum and accumulations?
    • Does the service require a pre-authorization?
    • Does the patient have out-of-network coverage if the provider is out-of-network with the payer?
  7. If the service requires authorization, contact the payer to determine their authorization process. 
  8. Inform the patient of their financial responsibility.
  9. Collect the patient’s responsibility before their scheduled appointment or treatment.

Gentem’s Real-Time Eligibility (RTE) is in beta testing and coming soon. If you would like to be notified when it is available, send us an email.

WATCH: Revenue Cycle Tips for Staying Independent

Many physicians are leaving private practice due to rising costs, lower reimbursement rates and staffing shortages. But staying independent is possible with a healthy revenue cycle.

Learn how to run a successful private practice with tips from this 20-minute webinar session.

eBook Cover for 5-Must Know Metrics To Build A Thriving Medical Practice

5 Must-Know Metrics To Build A Thriving Medical Practice

With this free guide, you’ll learn the key metrics that inform your practice’s financial performance and how best to optimize them to support practice growth.

Subscribe To Our Newsletter

Related Articles

Eliminate your medical billing headaches today.