Revisiting Eligibility Checks: Are You Doing Them Wrong?

June 30, 2015 by Antonio Arias, MBA, CHBME

Topics: Medical Billing, Revenue Cycle Management, Practice Management

We can’t stress it enough: checking a patient’s insurance in advance of each and every encounter is the number one way to avoid medical billing issues. So why do so many practices neglect them?

To be fair, few medical offices skip eligibility checks altogether: Almost every practice conducts an insurance check before seeing a new patient, and plenty of offices utilize technology systems that automatically verify insurance as part of the revenue cycle management process.

Yet the majority of medical practices occupy a ‘gray area’ when it comes to eligibility checks –falling somewhere on the spectrum between diligence and disregard. That’s why it’s crucial for every practice manager to revisit their eligibility-related processes regularly – annually, at minimum – to make sure insurance checks haven’t fallen off of the front desk team’s priority list. (If they have, it may be time for a change. Consider how contracting with a medical billing firm could help your practice reprioritize.)

As you reassess your verification efforts, consider each of the following areas. If you’re slacking in a particular one (pre-authorizations, patient financial responsibility, or otherwise), retrain your team on eligibility checks and their importance.

Insurance Card Review: How frequently do you ask patients for their insurance cards? First-time visitors aren’t the only ones who should furnish cards upon arrival. It’s imperative to ask every patient if there have been any changes in their insurance since their last visit, and require patients to let you make a fresh copy at least once or twice per year. For more frequent patients, periodically follow up with the insurer to make sure the information you have on file for the plan is accurate.

Network/Coverage Status: With the rise of exchange-purchased healthcare plans, coverage lines have blurred more than ever. Your practice may accept employer-sponsored Humana plans but not ACA ones, or you may be in-network for a Silver exchange plan but not for a Bronze. If there’s any ambiguity, get on the phone and ask the payer the particulars.

Patient Responsibility: Co-pay? Or co-insurance? Never assume, even if you feel highly familiar with the patient and his or her coverage – plans change all the time. 

Referrals & Pre-Authorizations: Services from a specialist not only may have a different co-pay or co-insurance amount (especially depending whether they’re in-network or out), but they also may not be covered at all unless they were properly referred or authorized. Specialists can find it very hard to fight denials for these issues, so there’s little room for error.

Deductibles: As part of the verification process, do your patients the favor of recognizing their long-term financial responsibility. Especially when checking eligibility for patients in for high-level encounters and other expensive services, ask the payer directly about the particulars of the patient’s deductible.

Still struggling? Streamline insurance verification and other back-office concerns by outsourcing to a medical billing company. Click here for more information.

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