Insurance eligibility verification is an important function of the medical billing cycle. It has the power to decide the fate of a claim for better or worse. Some offices don’t give adequate significance to doing insurance eligibility verification. We have the idea that certain claims don’t require insurance eligibility verification so healthcare personnel fail to foresee the consequences that will be faced by not doing the verification. The loss is to be borne by physicians or patients. To avoid denials and resubmission medical billers need to adhere to have a firm process of verifying coverage, which will be initiated by doing insurance eligibility verification irrespective of whether it is an ordinary health plan, PIP or workmen comp.

Medical Insurance Billing – 20 Verify to Reduce Denials

The issues created by non-verification are as follows:

  • Verifying the effective date is essential to avoid denials due to the expiration of insurance coverage and benefits.
  • Patient’s primary insurance becomes expired and he/she uses the secondary insurance that doesn’t cover the ailment and the claim is denied.
  • Patient may not have paid the premium and his/her insurance coverage has expired. It is important for the physician to know this earlier in order to make out payment details from the patient before treatment is given.
  • To find the primary insurance carrier of a patient, it is essential to do insurance eligibility verification.
  • In case the patient is covered under multiple health plans, insurance eligibility verification is essential to bill the correct plan.
  • If a patient changed his/her health plan but not informed the provider, the claim could be denied.
  • Some carriers accept the claim only if it is submitted in the name of a physician who is qualified for that service.
  • The possibilities of claim denial are more when the provider is not in par with the insurance company.
  • Deductibles, co-pays—Checking if there are deductibles and co-pay for the patient in order to avoid any confusions with the payment.
  • For some services pre-authorization is essential from the insurance carriers and if not the claims would be denied
  • Some carriers may have visit limits to the insured and incase if the visit limit of the patient has exceeded, then it will not be covered under insurance plan.
  • Some lab services are not covered under certain health plans and the claims are likely to get denied if the lab tests are not done in a preferred lab.

By doing thorough insurance eligibility verification, providers can avoid losses, delays and resubmittals. Insurance eligibility verification also saves time by avoiding the unnecessary billing process for a claim which is sure to get denied due to issues with the insurance coverage.

 

By: Dawn Moreno, PhD, CBCS, CMAA, MTC. Lives in the beautiful Southwest United States and has been an instructor for medical coding/billing for the past 7 years. Interested in quality medical billing training?

To know more Details about Medical Insurance Billing

Medical Insurance and Billing | Medigap Insurance for Medical Billers

AAPC – Best Practices to Verify Patient Insurance Info

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