Significance of verifying patients' eligibility and benefits

  • Written by Yash Rajan
  • Monday 5th September 2022
Significance of verifying patients' eligibility and benefits VLMS Healthcare

The first step of the medical billing cycle starts with interviewing the patient regarding their insurance benefits. This interaction is supposed to help the physician gather patients' personal information and understand their health insurance status. Based on this collected information, both physician and patient can know the services which are covered under insurance and services which are not. It also helps in letting the patient know about the co-pay amount. Successful verification of patients' eligibility and the insurance benefits assists in getting the desired reimbursements and avoiding the claim denials. The health insurance payers require a large pool of information to validate any medical service for which an insurance claim is being made. It is necessary to understand the medical need and the appropriateness of the provided service, either diagnostic or therapeutic. Such understanding helps health insurance payers clear the insurance claim and offer reimbursements to healthcare service providers. While documenting the patients' medical profile, one should note the essential details such as patients' name, age, date of birth, gender, and the type and status of their insurance plan. The guarantor is responsible for the billing process if the patient cannot. Hence, collecting their information is just as necessary to avoid loss of revenue.

It is crucial to verify the patients’ eligibility and the benefits provided under their insurance plan before administering any form of service. Generally, a healthcare professional should perform the eligibility checks before 48 hours of appointment. It gives the healthcare professional enough time to understand the patients' insurance plan. It also suggests the co-payment must be collected from the patient when providing care. Timely verification of patients’ details saves the rush for documentation after care delivery, which often causes errors in charge entry.

While addressing the patient, one should take a note of the following points:

  • Understand the insurance plan of the patient. It should cover the care which you are going to offer.
  • Interact with the patient regarding the type of their insurance plan, number of insurances they have and recent changes in their insurance plan.
  • For services such as mental health and addiction, many insurance payers have specific guidelines. Such guidelines must be followed while offering the care.
  • Some insurance payers have a ceiling point on the number of visits, hours of care, and the cost of care. The healthcare provider must be aware of this.
  • Interact with the patient regarding co-payment, co-insurance, and deductibles. It avoids the further complications leading to claim denials.

Having an efficient system for performing the verification process for patients' eligibility and benefits offered under their insurance plan means maximum reimbursements. Implementing such a practice is not an immediate operation. The healthcare providers must learn from the denied claims about the mistakes that must be corrected and issues that must be fixed. Frequent audits of an organization's billing system can help in highlighting such issues. Such practices can help the organization in having a perfect medical billing cycle.

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