Insurance eligibility verification is the process of checking a patient’s active insurance coverage to ensure that the amount they owe the medical practice for their medical treatment will be covered by the insurance provider. Successful medical billing depends on prompt and complete insurance eligibility verification. A patient’s medical claims will only be reimbursed in full if insurance coverage was afforded at the time that medical care was provided.

Without the proper systems and practices in place, hospitals and other healthcare providers could face huge losses as claims are denied despite the patient being deemed covered initially. The eligibility of a patient’s insurance claims needs to be checked on more than one occasion to ensure that the patient can afford the treatment with the proper medical insurance coverage in place.

Why Is Insurance Eligibility Verification Important?

Why Is Insurance Eligibility Verification

Verifying active coverage well in advance of the medical procedures allows the medical practice to estimate the total patient responsibility for payment. By providing an estimate for the total medical costs to the patient before their appointment, patients are more likely to come to the appointment prepared to pay or have payment plans figured out so that they can afford to get treated. Insurance eligibility verification ensures that healthcare providers will get paid for their services. This is because active coverage means that claims will be reimbursed without a hitch.

Insurance eligibility verification is also useful because a lot of the time patients are sure they have coverage when in fact their deductibles have changed or coverage was terminated for some reason. This directly impacts the amount of the money they will have to pay out of pocket to receive the medical treatment they need. Informing patients about their coverage as soon as possible helps them budget in the extra costs or find ways to work with the medical practice to generate a schedule of payment.

Finally, insurance eligibility verification allows healthcare providers to help their patients get all the information they need ahead of time so that they are not shocked to find out that they owe huge amounts in medical bills post procedure. In the same way, verifying insurance eligibility in advance protects healthcare providers from situations where insurance has lapsed. It can also help them in cases where the insurance policies that are still in effect do not cover the medical services or treatments that were provided.

Insurance Verification Checklist

insurance eligibility check list

Medical practices and hospitals need to spend enough time verifying their patient’s insurance coverage. This is to ensure that that all medical services and procedures that are provided can be reimbursed accordingly.

There are a number of details that insurance eligibility verification will need to confirm, which includes:

  • Patient’s name
  • Date of birth
  • Social Security number
  • Address
  • Insurance carrier’s name
  • Group number
  • ID number
  • Type of plan
  • Coverage details
  • Policy status
  • Effective date
  • Plan exclusions
  • Payable benefits
  • Co-insurance, co-pays & deductibles
  • Pre-authorizations & referrals
  • Health insurance caps
  • Address for claims submission
  • Type of Medicare coverage
  • DME coverage
  • Out-of-network benefits

What Does the Insurance Eligibility Verification Process Look Like?

insurance eligibility verification process by MedBillingExperts

All insurance eligibility verification solutions follow a specific process to ensure that insurance coverage is in fact in effect. It consists of the following 6 steps:

Patient Scheduling

By using automated appointment scheduling software, patients can get their medical conditions or symptoms assessed by a professional. Patients can also book appointments with their healthcare provider using an online portal so that they can come in to get their medical concerns checked out.

Patient Enrollment

Once the appointment has been scheduled, the patient’s demographic data can be entered into the system. Personal information like their name, date of birth, and home address will be required to begin with. Consequently, more important information like their diagnosis, allergies, and medical history will also need to be entered into the healthcare provider’s systems.

Insurance Eligibility Verification

Only once all the data has been entered into the system can this important revenue cycle management step be carried out. Front office staff will either go online or make calls to the listed insurance provider to gather detailed information about the patient. The type of information they need to collect includes the patient’s insurance coverage, deductibles, plan exclusions, pre-authorizations, and out-of-network benefits – to name a few.


Once all the insurance details and coverage has been confirmed, prior authorization for certain medical treatments is obtained from the insurance company.

Patient Follow-Up

Once all that information has been collected, the healthcare provider may need to contact the patient to inform them of their coverage and financial responsibilities in getting the medical treatment. All out-of-pocket costs will have to be explained in full so that the patient is well aware of the situation before they confirm that they want to proceed with the medical treatment.

Update Billing Software

All the insurance coverage details, pre-authorizations, and personal patient data are then updated in the billing software so that medical bills can be generated when they are needed.

Benefits of Outsourcing Insurance Verification Services?

Benefits of Outsourcing Insurance Verification Services

Insurance eligibility verification can be a time-consuming and tedious process. If not done right, it can lead to costly claims denials, increased A/R days, and delayed pay-outs. Poor insurance eligibility verification practices can also result in needing claims re-submissions and rework. This ultimately means that healthcare providers will face reduced cash flow and incur huge losses from patients who are unable to pay their medical bills.

This is because their patients only received the treatment thinking they had coverage in place at the time. If you find that your front office staff are overworked and your insurance verification process needs drastic improvements, perhaps it is time to consider outsourcing.

Outsourcing your insurance eligibility verification requirements to an insurance verification company can deliver major benefits. Some of these include:

Focus on Core Competencies

Insurance verification companies can help you focus on your core competencies. This is because outsourcing to them allows you to focus on providing high quality medical care, not worrying about paperwork. In fact, your front office staff will no longer need to chase patients or insurance companies to get the necessary data to update your system for successful medical billing. By allowing the experts to handle insurance eligibility verification, you are leaving more room for you to manage only that which you know best – the patients.

Streamline Business Operations

You can also streamline your business operations with proper insurance eligibility verification. By not leaving it to your front office staff to manage, outsourcing insurance verification will help you automate repetitive steps in the process like asking insurance companies for the policy details and coverages.

Outsourcing insurance verification to the experts means that they will take control of the required steps and standardize them into certain processes so that the entire cycle only takes a certain amount of time, every time. This essentially means that your business operations and processes have been streamlined to save time and effort in the long run. Greater efficiencies will result from this process standardization, which will help you require less resources as a result as well.

Reduce Risk Factors

Outsourcing insurance eligibility verification services to the experts will help you reduce risk factors that may adversely affect your practice. This is because having an efficient verification process in place will protect your bottom line. You can rest assured that every patient that is in the system has been checked and their insurance coverage has been confirmed so that you are not left with denied claims or huge losses from non-payment at the end of the day. When you prioritize insurance verification as a healthcare provider, you are ensuring that you will get paid on time, every time. In this way, denial management is no longer a concern for your practice.

Fewer Claims Rejections

When you outsource insurance eligibility verification services to third-party service providers, you are dealing with the professionals in their field of expertise. These seasoned professionals know what red flags to look out for when establishing whether you have active coverage or not. For example, if you have coverage but certain medical procedures are not covered by the insurance policy, they will know of it.

This is because they have dealt with hundreds, if not thousands, of patients and have a good sense of which services are covered by a certain type of policy. This means that fewer claims rejections will surface as the experts have done all the work that is required to ensure that cash flow is guaranteed for your practice.

Accelerated Billing Cycles

Entrusting insurance eligibility verification to outsourcing partners will help you accelerate your billing cycles as well. The experts will know what information to ask for, which data needs to be reconfirmed, and what medical services may be excluded from the plan. When these details are efficiently gathered and there is less follow-up that is required with both the patients and the insurance companies, billing cycles will certainly be accelerated as a result.

In fact, once the necessary data has been collected, these outsourcing professionals can as good as guarantee that no non-payment or denied claims will result from their efforts. Patients too can expect zero complications to arise once they have been processed. This is because the professionals have looked through their paperwork and only approved medical care for those that have sufficient coverage or disposable income to afford the services.

Boost Staff Productivity

You can look forward to your staff’s productivity being boosted as having professionals taking care of insurance eligibility verification means that more will get done in less time. Fewer human resources will be required to conduct this verification process.

This is because the ones that are responsible for taking care of it have expertise under their belt. You may even expect to be able to handle larger business volumes as the outsourced team is able to process more patients for insurance coverage than a team of in-house front office staff ever could. As the professionals are able to handle larger volumes of data in less time, you may even see your revenues grow as more business comes through the door.

Reduced Claims Reworking

Insurance eligibility verification services can be tedious and complicated if experts are not in charge. When third-party insurance verification companies are roped in to help out, you can almost always expect that there will be less rework involved. As experts, they are trained to get coverage information and pre-authorizations well in advance.

They also ensure that they have all the insurance information they require and that they got everything right the first time around. If your resources are able to get everything right the first time, there is no room for rework. This then also means that claims will no longer experience delays or require resubmissions so that denial management is barely a concern at your practice.

Cut Operational Costs

Outsourcing insurance eligibility verification services is a sure-fire way to cut operational costs. This is because fewer resources are required to process your patient’s insurance coverage. Hiring more front office staff to process larger business volumes results in greater inefficiencies as the new hires need to be trained until they gain proficiency in the process before they can prove useful to your practice.

Outsourcing to the experts means that fewer personnel need to be hired as they are highly efficient when it comes to all things related to insurance verification. Their cost per head is also very economical, since they work from third world countries. By employing less resources, who add more value to your operations, outsourcing will help you cut down your operational costs long term.

Identify Core Reasons for Unpaid Claims

Outsourcing insurance eligibility verification services to third-party service providers means that you are entrusting a team of dedicated experts to handle your insurance verification requirements. Over time, these professionals will generate reports to track all your claims activities to see how to bring in more revenue for your practice.

These experts will be able to isolate the core reasons for your unpaid claims. This is because pattern recognition means that they are familiar enough with your practices to determine which task or step in the process is causing the greatest amount of claims denials. By flagging the root cause of your unpaid claims, you can then set up processes to prevent claims denials from occurring and bring in greater revenues as a result.

Improved Cash Flow

By trusting your requirements to seasoned experts in the business, you are essentially cutting out inefficiencies and errors in the process. These inefficiencies may stem from poorly trained personnel or inadequate verification. Accurate insurance eligibility verification ensures that a greater number of clean claims pass through the system, which then speeds up approval times and results in a faster billing cycle. Just as inadequate verification of plan-specific benefits puts you at greater risk of denials, a thorough verification process will bring in greater cash flow and fewer denials.

The RCM process is fraught with thousands of inefficiencies and sources of errors for healthcare providers. These errors can cut into your revenues if they are not addressed in a timely manner. As the first major step in the RCM process, insurance eligibility verification is critical as it can make or break your practice. If amateurs or new hires are entrusted to handle the complexities of insurance eligibility verification, you might as well as throw in the towel. This is because your business will be inundated with claims denials and losses.

Outsourcing, however, can turn your luck around. You not only stand to cut operational costs and boost your staff’s productivity but can also focus on your core competencies and deal with faster billing cycles. You can look forward to these benefits and dozens more when you choose to outsource your insurance eligibility verification services to a third-party service provider.

Who We Are and Why Our Opinion Matters?

This article is brought to you by MedBillingExperts, a world leading revenue cycle management solution provider. With the over 10 years of experience we hold in providing end-to-end solutions for all our clients revenue cycle management requirements, we are able to dissect different RCM processes and create better ways to handle them. We provide insurance verification services that ensure patients are in fact covered by their insurance policies so that no unforeseen situations arise later on when it comes time to pay the medical bill. Healthcare practices and professionals come to us to get expert advice, understand upcoming trends, and gain current knowledge on industry best practices.


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