Key Guidelines for Patient Eligibility and Benefits Verification

  • Written by Zack Rutherford
  • Wednesday 21st December 2022
Key Guidelines for Patient Eligibility and Benefits Verification VLMS Healthcare

The healthcare industry is witnessing an increase in patients due to rising health issues and illnesses. After availing of healthcare services, it is the responsibility of patients to pay all the expenses. High deductible health plans (HDHPs) expansion is a blatant sign of this development. Therefore, it becomes crucial for patients to understand their responsibility for payment. Here, we will highlight the importance of patient eligibility and benefits verification. 

What is patient eligibility and benefits verification?

Any healthcare provider should verify the patient’s coverage for medical services and make them aware of their payment responsibility. Healthcare practitioners can understand the coverage offered by health plans and co-payments by patient eligibility and verification process. The collection of coverage status is facilitated by eligibility verification, and the risk of claims being turned down is decreased. It makes it possible for healthcare providers to strategically collect payments from patients and avoids interruptions in cash realization.

Manually and electronically eligibility verification process

Many of the payers and patients have access to check their eligibility online. The verification of eligibility done through a manual process and electronically before the patient appointment will help in:

  • Getting real information about a patient's insurance and a clear understanding of the benefits of health plans. 
  • Determining if you can get paid at the time of service
  • Updating insurance details
  • Getting patients to update primary care physicians' details. 

It could be required to call the payer from time to time with inquiries about the prerequisites for prior authorization or to explain certain aspects of eligibility and benefits.

The cruciality of eligibility checks

The eligibility of the patient should be checked 48 hours before the visit. If this is not feasible, it can be done in real-time before the treatment upon checking in. Quick eligibility checks assist you in lowering claim denials and rejections. The majority of revenue cycle management and electronic health record systems feature electronic eligibility checking capabilities. Your practice may minimize denials and increase revenue by checking the patient's insurance before providing service.

Significance of documentation

Your practice has certain requirements. The eligibility verification standards for a hospital or radiology clinic are substantially different from those for a drug use support clinic. As a result, each institution needs to develop its own protocols for verifying benefits and eligibility. Your team members must work well together to complete each phase with efficiency.

Outsourcing eligibility and verification process

You can get assistance from a third-party service provider with the processes involved in benefits and eligibility verification. Their training procedures enable you to hire experts for less money and lighten the pressure on your revenue cycle team. Some benefits of outsourcing are:

  • Allow the workforce more time to work on revenue cycle and other patient experience enhancement tasks.
  • Enhance and accelerate the delivery of care.
  • Eliminate denials and focus on increased cash flow.
  • Cost cuttings through labor negotiations
  • Preservation of policies and standards
  • Shifts the emphasis to denial prevention by lowering the frequency of denials related to eligibility and benefits.

VLMS Global Healthcare’s competent eligibility and benefits verification

The financial stability of your organization depends on effective eligibility and benefits verification procedures. The mechanism is also largely responsible for claim denials. Every rejection must be used as an opportunity to grow. Experienced revenue cycle professionals from VLMS Global Healthcare are available to assist the front-office workers with the eligibility and benefits verification procedures. 

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