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.

example of real time estimate

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

Insurance eligibility verification can be a cumbersome process if your staff doesn’t have a billing platform with real-time insurance eligibility verification. Manual checks, including phone calls to payers, can take five to 15 minutes (or more!) per patient.

But with real-time eligibility (RTE) and benefits checks, you can save your team hours, giving them more time to focus on patient care and business growth. 

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.

How to Streamline Your Medical Insurance Verification Process

Gentem Boost gives you the power to get instant and reliable verification of benefits for all insurance payers in one place. Our system allows providers to check patient eligibility within seconds, helping you spend more time with your patient, increase revenue and streamline the insurance verification process. 

With Gentem Boost, you will:

  • Avoid switching between different payer portals, websites, tools and phone calls. Gentem uses powerful technology to check payer sources and clearinghouses for you. Plus, our team can handle manual phone calls to payers.
  • Save time and avoid costly claim denials by setting up automated pre-appointment insurance checks for all your patients.
  • Increase upfront collections by sending HIPAA-compliant text or email patient estimates before the patient comes to your office. 

image of a lightbulb with a checkmark inside

With a three-minute setup and seven-day free trial, you can increase patient payments by the time your next patient walks in the door. Schedule a free demo today.


Request a Demo

Are You Giving Your Patients the Experience They Expect?

E&B checks and cost estimates are becoming a ‘must-have’ but take time. See how to do AI-driven eligibility checks instantly, with estimates sent by text or email with the click of a button.

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.