Understanding eligibility: 5 questions answered

By verifying eligibility, practices can determine a patient’s medical insurance coverage status prior to the appointment and report demographic information accurately on insurance claims.

Additionally, prioritizing eligibility promotes proactive patient collection measures and prevents payment delays. Neglecting to check eligibility is a common reason for medical claim rejections and denials.

Want to prevent denials and increase your practice’s clean claim rate? Read on for answers to your eligibility questions.

1. How does a practice check eligibility?

Practices can use two different methods to verify eligibility — electronic real-time eligibility checks or manual checking. It is a best practice to use electronic real-time eligibility to run checks at least 48 hours before the patient’s appointment.

This method allows you to ...

• Gain access to the patient’s insurance status and benefits prior to the visit.
• Request updates from the patient and advise if a copay is due at time of service.
• Verify updated insurance and ensure the account is notated for expedited check-in.
• Ask patients to update their primary care physician (PCP) and coordination of benefits (COB).

While it is less efficient, manually checking eligibility may be necessary to ask the insurance company specific questions regarding the patient’s benefit plan. Simply call the insurance company’s contact number listed on the back of the patient’s insurance card or log into the payer’s web portal.

2. What eligibility coverage information is provided?

The following information should be provided for every patient:

• Subscriber name
• Patient name
• Patient’s relationship to subscriber
• Patient date of birth
• Patient gender
• Patient member number
• Group name and number
• Plan type coverage date (policy effective date)

Beyond that list, payers may send additional information if available in the health plan’s records and appropriate to the coverage. This may include other insurance coverage in effect, PCP, and eligibility status. However, the accuracy of this information cannot be assured.

3. When should eligibility be checked?

Practices should proactively check eligibility. The most effective time is before the patient is seen by the physician, ideally 48 hours before the visit. In the alternative, this process can take place anytime up until, or at, check-in. Front-office staff should always ask patients if their insurance has changed since their last visit.

Tip: Keep a current, legible copy of the patient insurance card(s) on file to reference during the billing process, as back-office billers may need to verify eligibility while working rejected and denied claims.

4. What are eligibility verification best practices?

To decrease denials and potential delays in revenue, verify a patient’s coverage prior to the visit using your EHR’s electronic eligibility feature.

Beyond that best practice, follow this checklist prior to the visit:

• Check for inactive plans and flag the accounts.
• Check for primary, secondary, and tertiary insurance. When patients have multiple insurance plans, remind them to update their COB with each payer. (Note that Medicaid is always considered the payer of last resort.)
• For patients 65 or older, it is always best to verify whether their insurance coverage is “traditional” Medicare coverage.
• Confirm the services covered under the patient’s insurance policy and whether a referral or prior authorization is needed.
• Ensure referrals and authorizations are approved, entered in the system, and linked to the correct visits.
• See if a benefit limit is listed, specifying how much of the benefit remains. Some plans may have limitations for the dollar amount of each visit or the frequency and time frame in which the services must be delivered (e.g., a benefit limit of 12 visits, with a visit limit of two visits per month). Note that insurance plans may indicate that the provider should call customer service for psychiatric and substance abuse benefits information.
• Determine if a copayment, coinsurance, or deductible payment should be collected.

When scheduling the patient, remember these steps …

• Obtain as much demographic information as possible. Some demographic details (i.e., preferred language, sex, race, ethnicity, and date of birth) will affect Meaningful Use (MU) reporting.
• Always ask if the patient has had a change in insurance, whether a new policy or change in coverage.

5. What are the benefits of a standard operating procedure (SOP) for checking patient eligibility?

It is recommended that you create a SOP for the eligibility workflows you utilize daily. For instance, the guidance offered in the SOP can include a recommended talk track for the front office staff to use when requesting delinquent balances of patients.

Documenting the processes that work for your practice will provide a knowledge bank for new employees to understand the steps required to complete tasks accurately and efficiently. Additionally, the SOP document will promote collaboration across the office by helping different roles understand how their actions influence the revenue cycle.

Strengthen your RCM with a trusted billing partner

Managing eligibility and benefits verification can feel daunting, especially in addition to all the other critical RCM steps. But you don’t have to do it all yourself! When you partner with Greenway Revenue Services, you can benefit from specialty-specific billing expertise and a team dedicated to helping you achieve your revenue goals.