Insurance verification services cover the process of verifying the insurance coverage of a patient visiting a healthcare services provider. To avoid rejection/delays in settlement of claims, it is essential to verify a patient’s insurance coverage before a patient is provided healthcare services. Insurance verification services help healthcare providers in improving their cash flow cycles and increase their revenues.
Methods of Verifying Patient Insurance Coverage:
Providers of healthcare insurance eligibility verification services employ two methods for verification: Over the phone and online.
Phone: This is a complex process, which starts by calling the insurance company. Every insurance card has a contact number of the insurance company. However, sometimes there are multiple numbers on each card. For insurance eligibility verification to be done for healthcare providers, the most crucial number is of provider services. Upon calling, there is a thorough authentication process to confirm that the call is from a verified healthcare services provider. This is a part of HIPAA compliance, Insurance companies cannot divulge sensitive patient information unless they are sure the call is from an authorized healthcare services provider. Once the verification is complete, insurance providers will ask for patient details such as their name, date of birth, and ID number.
Upon locating the details of the patient, the insurance provider can provide all the critical information needed for insurance verification.
Online: While this option is not provided by all insurance companies, where available, this is a faster and more efficient way of verifying patient insurance coverage. Online verification is done through clearinghouses. The clearinghouses provide with all the essential information needed to check the status of a patient’s insurance. Simply log in to their site, enter the patient’s information, and get all the details you need.
Some insurance providers have their information portal, thus eliminating the need for a clearinghouse. You can get the necessary information from this portal at the click of a button.
While the online process is much faster, it involves a monthly subscription fee to a clearinghouse. In order to access information directly from an insurance provider, there is a need to register as a contracted healthcare services provider. In the absence of a clearinghouse or insurance provider’s portal, healthcare providers will have to rely on the traditional and time-consuming way of verifying insurance eligibility through telephone.
Steps Involved in Insurance Eligibility Verification Services:
Let us look at the things needed to verify patient insurance coverage.
Receiving schedules of patients: Verification of medical insurance eligibility starts much before a patient visits a healthcare provider. Healthcare providers provide a schedule of their patients to their chosen insurance verification services company. These schedules can be exchanged via fax, email, or Electronic Data Interchange (EDI.)
Checking of documents: The first step is to verify whether a patient’s insurance coverage is active. This includes verifying things like whether they have paid their premiums on time. If a patient is claiming benefits on someone else’s insurance coverage, you need to verify whether this person is clearly listed as a dependent in the insurance plan. As a part of this stage, all the insurance documents are thoroughly checked to ensure they are aligned with the requirements of insurance companies or payers.
Verification of coverage: The checks mentioned above can give a confirmation that the patient’s insurance coverage is active. As a next step, insurance verification companies start verifying the coverage with all primary and secondary payers. As mentioned above, this first level verification is done either via phone or online. The verification of coverage does not end here. It is followed up by a second-level verification, which involves assessing ‘code-specific’ eligibility. For example, outpatient services are reported using the CPT system of medical coding, whereas CDT codes are used for dental services. Different codes have different annual max or lifetime limits and authorizations, and these need to be looked at thoroughly during verification of medical insurance eligibility.
Verification of benefits: A further check is needed to confirm whether the specific procedures, diagnosis and services required by the patient are covered under their insurance plan. For example, some insurance plans may include preventative checks, but exclude the use of emergency care services. If a patient with such a plan is using emergency care services, it will lead to a rejection of the claim by the insurance provider, and losses to the healthcare services provider.
The same thing also applies to group plans. If a large employer, like Amazon, is taking insurance for its employees, it can negotiate better with the insurance provider and get more benefits. The same benefits may not be available for employees of a small organization. When dealing with group plans, care needs to be taken to verify the specific benefits available under the coverage. As part of the verification of insurance, all these benefits are verified with the insurance provider even before the patient enters the healthcare facility.
Verification based on the type of plan: Insurance providers offer different types of plans to meet different budgets and health needs. For example, a Health Maintenance Organizations (HMO) plan gives limited freedom to a patient to choose their healthcare providers and requires the least amount of paperwork. At the same time, a Point-of-Service plan gives more freedom to patients and involves a moderate amount of paperwork. A Preferred Provider Organization (PPO) plan leads to higher costs to patients if they see out-of-network doctors. Also, deductibles may vary according to plan. Typically, the less expensive a plan is, the higher is the deductible amount.
Likewise, copay and coinsurance may also vary based on the plan. Copay is a flat fee paid by the patient when receiving care. Coinsurance refers to the percentage of care charges to be borne by a patient. If a patient has a plan with a higher premium, the coinsurance amount will be lower.
The insurance verification process will vary depending on the type of plan chosen by patients.
Checking for required referrals or pre-authorizations: Some insurance plans, such as an HMO plan, require a referral from a primary care physician before visiting a specialist. For example, a patient cannot decide on their own whether they need to see a cardiologist without a referral from their primary care physician. Pre-authorizations refer to prior authorization from the insurance provider before certain tests or surgeries. This check helps insurance providers in ensuring whether a certain test is medically appropriate for a patient.
Following up with patients: At times, additional follow up is needed with patients for any additional or missing information. This helps in cross-checking the information, and ensuring the final submission is free of errors.
Submission of a final report: Once verification is complete, insurance verification services companies submit a detailed final report to the healthcare services provider. This includes details on the type of plan, coverage, plan exclusions, payable benefits, and much more. For example, the detailed final report will also include out of network benefits. It will also include whether the patient has Durable Medical Equipment (DME) coverage. The final report also includes information such as whether the recommended procedure is needed medically, and information on pre-existing conditions, if any, which may lead to a denial of a claim.
How to Choose the Right Medical Insurance Verification Partner?
Once a decision has been made to outsource insurance eligibility verification services, the next step is to shortlist the right partner. Several factors need to be considered before choosing the right insurance verification services company.
Coverage of specialities: When outsourcing healthcare insurance verification services, the first thing to look out for is the range of specialities covered by an insurance verification services company. For example, the process of assessing insurance eligibility for dentistry is different from, say, ophthalmology, or optometry. You should ensure your medical insurance verification partner is well versed with the specialities covered within your practice.
Knowledge of medical insurance plans and providers: A good insurance verification services provider should have a thorough knowledge of various medical insurance plans. They should also be well-versed in the requirements of private medical insurance providers as well as government-sponsored programs like Medicare and Medicaid. Different insurance providers have different requirements. By choosing a partner who knows what to look out for when verifying different types of insurance, you can reduce the time spent on processing claims and minimize the risk of rejections.
HIPAA compliance: HIPAA Compliance is essential for the protection of sensitive patient information. You should choose a HIPAA compliant insurance verification services provider to ensure your patient data is protected. Choosing a non-HIPAA compliant partner can lead to expensive fines (as high as $1.5 million) for violation.
Benefits of Outsourcing Insurance Eligibility Verification Services:
Insurance verification is a crucial step in the revenue management cycle of healthcare providers. If the healthcare provider admits patients without appropriate coverage, it can lead to expensive denials of claims, increased accounts receivables, and delays in payouts. Incorrect insurance verification procedures can also lead to rework and wastage of precious time. There are many advantages to outsourcing insurance eligibility verification services.
Get Professional Expertise: Traditionally, the process of insurance verification has been carried out by the front office staff of a healthcare services provider. However, on a typical day, the front-office staff is loaded with a lot many other responsibilities, which can lead to errors in insurance verification. Also, not all front office staff may be qualified to deal with the technicalities of insurance verification. In contrast, insurance verification companies employ professionals with a background and training in insurance verification. Also, these professionals have substantial experience in dealing with different kinds of insurance plans and procedures.
Minimize Risk of Errors: By outsourcing healthcare insurance verification services, the front-office staff can focus on their core competencies. And the amount spent on outsourcing insurance verification to professionals is negligible as compared to the costly losses, which may occur due to incorrect insurance verification.
Reduce Claims Rejections: By outsourcing insurance eligibility verification services, healthcare providers can reduce rejections of claims. When professionals are involved in healthcare insurance verification services, they are dealing with these verification processes day in and day out. As such, they are thoroughly trained to look out for things that may lead to denial of claims or delays in settlements at a later stage.
Usage of Technology: The use of technology makes the insurance verification more efficient and minimizes errors. For example, the right technology allows for batch processing of inquiries, which may not be possible when verification is done by front-level staff. Insurance verification services companies provide a technological edge in this process, resulting in a significant improvement in productivity and accounts receivable days.
Improved Efficiency for Medical Billers: In any healthcare setup, there are three parties involved – patients, healthcare providers, and insurers. Medical billers negotiate and arrange for settlements of payment between these three parties. The key role of medical billers is to ensure that healthcare providers (e.g. hospitals, physicians, or any other providers of health services) are adequately compensated for their services.
Outsourcing insurance verification means medical billers no longer have to coordinate with front-office staff. They can coordinate with professionals who are technically trained on insurance verification, thus increasing the efficiency of medical billers. This also means medical billers have to deal with fewer errors, like admitting a patient with an inactive insurance policy.
Why Choose OutsourceRCM for Healthcare Insurance Eligibility Verification Services?
OutsourceRCM has more than ten years of experience in providing insurance verification services. A wide range of medical billing companies, hospitals, physicians and urgent care centres have chosen OutsourceRCM for outsourcing insurance eligibility verification services. Our team of professional insurance verifiers knows what it takes to provide fast and accurate insurance eligibility verification to make your practice more efficient and minimize claims-related losses. Our 4-step eligibility verification process starts even before the patient has entered the hospital and ends only after the revenue cycle is complete, and the billing system is updated.
