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Best Practices for Patient Eligibility Verification

Best Practices for Patient Eligibility Verification

As any practice administrator knows, the process of getting paid starts far before the patient steps foot in the office. What some fail to see is the critical importance of the first step in the revenue cycle: patient eligibility verification. Without a foolproof process in place, even the smallest documentation error or verification oversight may generate significant roadblocks to reimbursement. Now more than ever, practices must root out and close the gaps in their verification process — failure to do so may jeopardize practice profitability.

Claim denials are increasing at an alarming rate, impacting providers in every corner of the healthcare industry. According to a recent Kaufman Hall survey, 67% of healthcare leaders saw an increase in claim denials in 2022 — a figure that more than doubled in just one year.1 Without taking the necessary steps to overhaul claims management, practices can almost guarantee that this trend will continue. The new Experian State of Claims survey found that shifting payer policies and an increase in claim inaccuracy are driving the denial increase.2

Verifying patient eligibility means more than checking a box. To minimize denials, your billing team should take the time to implement necessary process improvements to ensure clean claim submission the first time.

Top four best practices for eligibility verification:

  1. Work proactively. Set your revenue cycle up for success by starting the process early. This means verifying eligibility before patients walk in the door — ideally when the appointment is scheduled. This gives your billing office time to make sure patients won’t be digging into their wallets for services no longer covered by insurance. Additionally, consider conducting routine verifications regularly throughout the year. That way, your staff (and your patients) are less likely to face any surprises when it comes time for the appointment.
  2. Maximize data collection. When it comes to eligibility verification, every detail counts. Train your billing team to triple-check every possible piece of information gathered from patients regarding demographics and insurance coverage: policy status, start and end dates, co-pays, co-insurances, out-of-pocket maximums, deductibles, plan exclusions, prior authorization needs, secondary policies, and any other policy details relevant to the services rendered. Finding missing information after the visit culminates in a game of phone tag with patients and insurers, delaying time to reimbursement and building frustration with your billing process.
  3. Conduct timely follow-ups. In some cases, verification is needed after a patient visit. Despite the change in timelines, your team should still work diligently to update the claim with complete and accurate details. This requires having a copy of the patient’s insurance card in your system — a necessary step in the check-in process. If the patient’s financial responsibility changes after processing the new claim, they should be notified right away and provided with a clear explanation of charges.
  4. Communicate patient responsibility early. As with any stakeholder in the billing process, patients want full transparency when discussing financial responsibility. Verifying information and calculating charges beforehand helps your team provide an accurate cost estimate when patients come into the office. This way, you avoid surprising patients with unexpected bills after the fact — a surefire way to decrease the likelihood of getting paid.

Don’t let your billing team get lost in the weeds of patient eligibility verification. Consider bringing in outside help from revenue cycle management experts trained to maximize efficiency and accuracy in every step of the revenue cycle. The Med USA team can help your practice perfect the verification process, maximize insurance reimbursements, and increase patient collections. Connect with a member of our team to learn more about how we can reduce claim denials and strengthen practice profitability.

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  1. 2022 State of Healthcare Performance Improvement: Mounting Pressures Pose New Challenges. (2022). Kaufman Hall. 
  2. The State of Claims Survey 2022. (2022). Experian Health.